Evidence on the Efficacy of Integrated Care

Evidence on the Efficacy of Integrated Care

Torben Larsen (University of Southern Denmark, Denmark)
DOI: 10.4018/978-1-60566-356-2.ch015
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The fragmented delivery of healthcare and social services was put on the agenda as a major problem by WHO in 2002. Early home-supported discharge (EHSD) of stroke patients combining efficacy with net savings represents a prototype of integrated care (IC) or overlapping services for better clinical continuity. Other frequent chronic conditions as heart failure, chronic obstructive pulmonary disease, and mental disease exhibit parallel results from home health interventions. A SWOT analysis of IC emphasizes: Strengths are 1) economic dominance, 2) benefits to a majority of the population, and 3) psychological motivators for the patient (Hawthorne effect). Weaknesses are 1) moderate improvements on a day-to-day basis, 2) some lack of RCT, and 3) lack of trust across settings. Opportunities are 1) job enrichment to health professionals, 2) low-tech improvements affordable to low and middle income countries, and 3) organisational quality. Threats are 1) fragmented financial conditions, 2) defensive specialists, and 3) mediocre implementations. A meso-strategy of implementation is recommended to EU (FP7): 1) Make a synthesis of existing and ongoing research as a health technology assessment (HTA) of IC in EU for improved interdisciplinary cooperation across the hospital and primary care interface for selected CC. 2) The organisational dimension should focus on the formation of country specific multidisciplinary networks on IC.
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Methods And Materials

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. 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 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

Key Terms in this Chapter

Analysis of Strengths, Weaknesses, Opportunities and Threats: (SWOT analysis) is a tool in strategic planning analysing the general conditions for implementations of a specific project.

Hawthorne Effect: is a term characterizing the action mechanism in human relations management (HRM) of industrial work groups as well as service organisations. Within IC the Hawthorne effect is related to values of social patient psychology” as feeling of security, participation and direct transference of skills.

Health Technology Assessment: (HTA) is according to the definition of EUnetHTA: ‘A multidisciplinary synthesis of medical, social, economic and ethical aspects of health interventions aiming the formulation of safe, effective health policies that are patient focused and seek best value’.

Integrated Care: (IC) is ‘overlapping services’ across the health and social sectors. Interventions that are coordinated at the management level, only, are not IC.

Early Home-Supported Discharge: (EHSD) is an elaboration of the research term “Early Supported Discharge (ESD)” explicating that the ESD has to be in the home of the patient. Stationary or out-patient municipal facilities are included in ESD but excluded in EHSD.

Activities of Daily Living: (ADL) are typical personal activities related to an ordinary home life i.e. walking, dressing, eating, washing, going to the restroom, etc. ADL is often measured by Barthel Index (BI)” or “Functional Independence Measure (FIM)”.

Meso-Strategy: is a term in strategic planning of health care systems that expresses the endeavour to integrate the best elements and avoid the disadvantages of centralized and decentralized planning, respectively.

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