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2012
KCE REPORT 1
DEVELCHROAPPEND
90S
LOPMENIC CAIX
ENT OF ARE IN B
A POSBELGIU
ITION PUM
PAPER FOR
www.kce.fgoov.be
2012
KCE REPORTS HEALTH SERV
DEVELIN BEL EDITORS: DOM CONTRIBUTINHAUCOTTE, JALINDA SYMON
190S VICES RESEARC
LOPMELGIUM
MINIQUE PAULU
NG AUTHORS: FEAN HEYRMAN, J
NS, THERESE VA
CH
ENT OF
S, KOEN VAN DE
ELICITY ALLEN, EAN MACQ, GEO
AN DURME, FLOR
A POS
EN HEEDE, RAF
SIBYL ANTHIERORGES OSEI-ASRENCE VANDEN
SITION
MERTENS
RENS, LIESBETHSSIBEY, VINCIANDORPE, BERT V
PAPER
H BORGERMANSNE QUOIDBACH, VRIJHOEF
R FOR C
S, ANJA DESOMROY REMMEN,
CHRON
ER, SOPHIE GEOLIVIER SCHMIT
www.kce.fgo
NIC CAR
ERKENS, GENEVTZ, HILDE SPITT
ov.be
RE
VIEVE TERS,
COLOPHOTitle: Editors: Contributing au
Reviewers: External expert
Acknowledgem
External validat
Stakeholders:
ON
thors:
ts:
ents:
tors:
Deve Dom Felic
VolksRIZIVQuoiAntwTher
Mem Daan
geria(Obs(UGevan BethHensMedi(Soc(Clin(SPFVlaan
PierrVolks
Prof.(Instide S
JohaindépCorinCoesEerst(Huis(VereVerh
elopment of a posinique Paulus, Ko
city Allen (Abacussgezongdheid –V), Jan Heyrmandbach (Cabinet d
werpen), Olivier Scese Van Durme (U
mbers of the consun Aeyels (Huis atrie), Claudine servatoire Santé dent), Claude DecuZiekenhuisapotheune (ANMC), Mics (Socialistische Mica), Luc Lefèbvreiété Scientifique diques Universitair
F Santé publique –nderen), Ilse Weere-Yves Bolen sgezondheid – SP Dr med. Reinhaitute of Tropical Mherbrooke, Canad
an Abrahams (St-pendantes de Benne Bouuaert (ULssens (Woon-teLijnsgezondheidsartsengroepsprakeniging Huisartseaegen (GBO / Ca
ition paper for chroen Van den Heeds International®), SPF Santé Publ (KULeuven), Jeade la Ministre deschmitz (UCL), HilUCL), Florence V
ultative and scientvoor GezondheidBaudart (Associadu Hainaut), Anneuyper (Fédération ekers), Aurore Dcky Fierens (LigueMutualiteit), Lon He (Société Scientdes Jeunes méderes UCL Mont-Go– FOD Volksgezo
eghmans (Vlaams(Région Wallon
PF Santé publiqueard Busse (Depa
Medicine, Antwerpda) Elisabeth Woon-
elgique), Marie-ClaLG), Pierre Cheva
en zorgcentrumdszorg Amberesktijk Het pleintjenkringen Zuiderkeartel), Marleen Ha
ronic care in Belgde, Raf Mertens Sibyl Anthierensique), Anja Desoan Macq (UCL), s Affaires Socialede Spitters (Unive
Vandendorpe (UCLtific sections of thed), Jean-Pierre Bation des infirme Beyen (Regionnationale des infie Wilde (Fédéra
e des Usagers deHoltzer (Associatietifique de Médec
ecins généralistesodinne), Jean-Luondheid), Luc Vans Patiëntenplatformnne), Brigitte Be), Ri De Ridder (Rartment of Healthpen), Prof. Martin
en zorgcentrum Haire Beaudelot (C
alier (UCL), Marleem St-Bernarduss, Antwerpen), e Booischot), Tiempen), Caroline aems (Kovag), Sa
ium – Appendix
s (Universiteit Anomer, Sophie GeGeorge Osei-Ass
es et de la Santéersiteit Tilburg), LL), Bert Vrijhoef (Ue Observatory for Baeyens (Belgisc
mières indépendaaal Ziekenhuis Hirmiers de Belgiqution Nationale de
es Services de Sae K.U.Leuven / Vlaine Générale), Lu
s – SSMJ), Frankc Vachiery (Hôpi
n Gorp (Katholiekem), Johan Wens (Bouton (Région RIZIV – INAMI), Sh Care Managem
Fortin (Départem
Hasselt), ,ClaudinCliniques Universen Cloes (Ligue e
s, Bertem), LeSofie De Mars
ne Devlieger (UDucenne (asbl Abine Henry (Ligue
twerpen), Liesbeerkens, Genevievsibey (Abacus Inté Publique), Roy Linda Symons (UnUniversiteit TilburgChronic diseases
che Vereniging vantes de BelgiquHeilig Hart Tienenue), Marc Dooms es Infirmiers de
anté), Johan Hellinaamse Overheid)uc Maes (E-Healtk Nobels (OLVZ Aital Erasme), Isabe Hogeschool Lim(Universiteit Antwe
Wallonne), ChStephen Mitchell (Ament Berlin, Germment de médecine
ne Baudart (Assoitaires Saint-Luc)en faveur des insentje Cools (Ss (Ziekenzorg
Universiteit AntweAidants Proches, Be Alzheimer), Jan
eth Borgermans (ve Haucotte (INAternational®), VincRemmen (Univerniversiteit Antwerpg) s voor gerontologieue), Luc Berghm
n), Jan De Maese(Belgische VerenBelgique), Xavie
ngs (ICURO), Eve, Tom Jacobs (Doth), Guillaume MAalst), Christian Sbelle Van der Br
mburg / Wit-Gele erpen) hris Decoster (Abacus Internatio
many), Prof Bart e de famille, Unive
ciation des infirm), Guy Beuken (Uuffisants rénaux),SamenwerkinginitCM), Jos Des
erpen), Ingrid DBelgrade), Anne Gnnie Hespel (Thuis
(FOD AMI –ciane rsiteit pen),
e en mans eneer niging er De elyne omus athot
Swine empt Kruis
(FOD onal®)
Criel ersité
ières UCL), Bart tiatief medt ruyts
Gillet-shulp
Members of t(also invited as
Conflict of intestakeholders:
Conflicts of intevalidators:
Layout:
the Steering Grostakeholders):
erest of experts a
erest declared by
vzw Jeande la(FéddomiMulti(ABS(Ziek(LandMinis(Dom
oup JeanDecoVolksHusdGenePubliAffairVolksVolks
and Invitewereinteredecla
the ReinChro
Ine V
Socialistische Mun Loiseau (Associaa Province de Lièération des Assoicile Liège-Huy-Wdisciplinair Netwe
SYM – BVAS), Jekenhuis Netwerk Adsbond van de Ostre de la Famille,mus Medica).
n-Pierre Baeyens oster (FOD Volksgsgezondheid – SPden (Cabinet Régeret (Cabinet du Mic de Wallonie, Dres Sociales et sgezondheid –sgezondheid), Ilse
ed experts, stakee contributing withests in the domaared other conflicthard Busse rece
onic Disease in Eu
Verhulst
utualiteiten), Hildeation des gestionnège), Kara Mazluociations de MédWaremme), Franerk Oost-Meetjeslean-François SouAntwerpen), Kristnafhankelijke Ziek de la Santé et de
(Belgische Veregezondheid – SPPF Santé publiqugion Wallonne), Ministre du Gouv
DG05), Louis Paqde la Santé PuSPF Santé pu
e Weeghmans (Vl
eholders, memberh their valuable eain of chronic carting interests, likelived funding link
urope” (2010) and
e Lamers (Alzheimnaires Publics de um (Dionysos), Sdecins Généralistençois Poncin (Rand & West-Meeupart (Forum destien Van Deyk (Ukenfondsen), Kares Affaires sociale
eniging voor gerPF Santé publiqueue), Micky FierensMarie-Claire Min
vernement de la Rquay (Wit-Gele Kublique), Dominiqublique), Isabellelaams Patiëntenp
rs of the Steeringexperience and kre, linked to theily to undermine thed to the author for several prese
mer Liga), MarinaMaisons de Repo
Saphia Mokrane (es de Bruxelles)
Réseau-Hépatite etjesland), Janneks Associations deZ Leuven), Omerin Van Sas (Praktes de la Commun
rontologie en gee), Ri De Ridder (s (Ligue des Usane (Fédération WRégion de BruxellKruis), Vinciane Qque Sege (Coccoe Van der Breplatform)
g Committee andknowledge of the r function in the he value of his conrship of the Obseentations on the to
a Lermytte (De Vos et de Maisons (Entraide Marolle, Christine Ori (aC Bruxelles), I
ke Ronse (UGente Généralistes), Pr Van Haute (UZ tijkhuis Baarle), Aauté germanopho
riatrie), Jacques RIZIV – INAMI), O
agers des ServiceWallonie-Bruxellesles-Capitale), Sop
Quoidbach (Cabinom), Saskia Vanmpt (SPF Sant
the Observatoryfield. In that reshealthcare secto
ntribution to this pervatory/WHO puopic (invited).
Volksmacht Turnh de Repos et de ss), Valentine Mu
asbl Aides et soiIlse Pynaert (Lo), Ferdinand SchrPaul Van den HeGent), Chris Van
Alfred Velz (Cabinone), Patrick Verd
Boly (ANMC), COlivier Grégoire (
es de Santé), Yols), Philippe Henrphie Lokietek (Senet de la Ministren Den Bogaert (té publique –
y for chronic disespect they might or. None of themproject. blication on “Tac
hout), soins sette ins à okaal reurs euvel n Hul et du
donck
Chris (FOD ande ry de ervice e des (FOD FOD
eases have
m has
ckling
Disclaimer:
Publication date
Domain:
MeSH:
NLM Classificat
Language:
Format:
Legal depot:
Copyright:
How to refer to
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tion:
this document?
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• Sfs
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lth Care Reform;
shed under a “by/tent/about-copyrig
Heede K, Mertenrvices Research 2012/10.273/85.
lable on the webs
sulted about a ng meetings. Thent. was submitted torocess between essarily all threeroved by commoerrors or omissi
bility of the KCE.
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/nc/nd” Creative Cghts-for-kce-repor
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site of the Belgian
(preliminary) veey did not co-au
o the validators.the validators. T
e agree with its con assent by theions that could p
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KCE Reports 19
TABL
92S
LE OF COONTENT1.1.1.1.1.
1.
1.
TS HIGHLIGH
1. OBJECTIV2. METHODS3. MAIN CHA4. THE NETH
1.4.1. S1.4.2. S1.4.3. E1.4.4. Im1.4.5. A1.4.6. O1.4.7. S
5. DENMARK1.5.1. S1.5.2. S1.5.3. E1.5.4. Im1.5.5. A1.5.6. O1.5.7. S
6. QUEBEC .1.6.1. S1.6.2. S1.6.3. E1.6.4. Im1.6.5. A1.6.6. O
Chronic care
HTS FROM FOURVE AND RESEARS ..........................ARACTERISTICSHERLANDS .........
Stakeholder CollabShared Data & PerEngaging Consummproving HealthcaAligning Finance &Outcomes .............Summary ..............K ..........................
Stakeholder CollabShared Data & PerEngaging Consummproving HealthcaAligning Finance &Outcomes .............Summary ..............
............................Stakeholder CollabShared Data & PerEngaging Consummproving HealthcaAligning Finance &Outcomes .............
e
R COUNTRIES –RCH QUESTIONS............................
S OF THE COUNT............................boration: shared Vrformance Measu
mers ......................are Delivery ........
& Insurance .............................................................................................boration ...............rformance Measu
mers ......................are Delivery ........
& Insurance .............................................................................................boration: shared Vrformance Measu
mers : some illustraare Delivery ........
& Insurance .....................................
THE CHRONIC CS .......................................................
TRIES ..............................................
Vision & Leadershurement ....................................................................................................................................................................................................................
urement ........................................................................................................................................................................................
Vision & Leadershurement ................ations .......................................................................................................
CARE MODEL IN................................................................................................................hip ............................................................................................................................................................................................................................................................................................................................................................................................................................................................hip ....................................................................................................................................................................
N USE ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
1
...... 7
...... 7
...... 7
.... 10
.... 11
.... 12
.... 13
.... 14
.... 14
.... 15
.... 16
.... 18
.... 19
.... 20
.... 22
.... 22
.... 23
.... 23
.... 24
.... 26
.... 27
.... 28
.... 30
.... 30
.... 31
.... 32
.... 33
2
1.
1.
1.
2.2.2.2.2.2.2.
2.
1.6.7. S7. PENNSYL
1.7.1. S1.7.2. S1.7.3. E1.7.4. Im1.7.5. A1.7.6. O1.7.7. S
8. FUTURE A1.8.1. F1.8.2. F1.8.3. F1.8.4. F
9. DISCUSS1.9.1. Im1.9.2. O1.9.3. B1.9.4. LOVERVIEW
1. QUALITY 2. CLINICAL3. MEDICAT4. CHRONIC5. PERSONA6. CHRONIC
18 AND 67. ORGANIZ
REHABILI
Chronic care
Summary ..............LVANIA ................Stakeholder CollabShared Data & PerEngaging Consummproving HealthcaAligning Finance &Outcomes .............Summary ..............ACTIONS IN THE
Future Actions in tFuture Actions in DFuture Actions in QFuture actions in PION .....................mplementation of Outcomes of redesBarriers in redesigLessons learned ...W OF KCE REPOAND ORGANIZA QUALITY INDICA
TION USE IN NURC LOW BACK PAIAL CONTRIBUTIO
C CARE OF PERS65 YEARS ............ZATION AND FINA
TATION IN BELG
e
............................
............................boration: Shared Vrformance Measu
mers ......................are Delivery ........
& Insurance .................................................................
E 4 COUNTRIES .he Netherlands ...Denmark ..............Quebec ................Pennsylvania ...................................the elements of thsigning chronic caning chronic care ............................ORTS ..................
ATION OF TYPE 2ATORS ...............
RSING HOMES ...N ........................
ON FOR HEALTHSONS WITH ACQ............................ANCING OF MUSGIUM ...................
............................
............................Vision & Leadersh
urement ....................................................................................................................................................................................................................................................................................................................................he CCM ...............are management . management .............................................................
2 DIABETES ............................................................................................
H CARE IN BELGQUIRED BRAIN IN
............................SCULOSKELETAL............................
............................
............................hip ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................IUM. IMPACT OF
NJURY BETWEEN............................L AND NEUROLO............................
KCE Report 1
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................
............................F SUPPLEMENTSN THE AGE OF ............................OGICAL ............................
192S
.... 35
.... 36
.... 37
.... 38
.... 39
.... 39
.... 40
.... 40
.... 42
.... 43
.... 43
.... 43
.... 44
.... 44
.... 45
.... 45
.... 47
.... 47
.... 48
.... 54
.... 54
.... 55
.... 55
.... 56 S .. 56
.... 57
.... 58
KCE Reports 19
92S
2.2.2.
2.
2.
2.2.
2.2.
2.2.
2.2.
2.2.
2.
2.2.2.
2.
2.
8. PHYSICIA9. FINANCIN10. QUALITY
QUO VAD11. EFFECTS
FINANCIA12. QUALITY
OF A SET13. LONG STA14. COMPAR
OF PRIMA15. DIFFEREN16. CONSUM
MEDICINE17. FATIGUE 18. MAKING G
AND RETE19. FINANCIN20. PHARMAC
DISEASE,21. ORGANIZ22. USE OF P
A HEALTH23. ADVANTA
‘PAY FOR24. FINANCIN25. FINANCIN26. THE REFE
USE OF L27. A FIRST S
HEALTHC28. SEAMLES
Chronic care
AN WORKFORCENG OF THE CARE
DEVELOPMENTDIS? ......................S OF THE MAXIMAL ACCESS TO H
INSURANCE FOT OF QUALITY INAY PATIENTS INISON OF THE COARY HEALTH CANTIATED PRACTPTION OF PHYSE IN BELGIUM ....SYNDROME: DIA
GENERAL PRACTENTION ..............
NG OF THE GERICEUTICAL AND N, A RAPID ASSES
ZATION OF PALLPOINT-OF-CARE H TECHNOLOGYAGES, DISADVANR QUALITY’ PROGNG OF HOME NUNG OF HOME NUERENCE PRICE
LOW COST DRUGSTEP TOWARDSCARE SYSTEM ....SS CARE FOR ME
e
E SUPPLY IN BELE PROGRAM FOR
T IN GENERAL PR............................UM BILLING SYS
HEALTH CARE ....R RECTAL CANCDICATORS ......... PSYCHIATRY T
OST AND THE QUARE IN BELGIUMTICE IN NURSINGSIOTHERAPY AND............................AGNOSIS, TREATICE ATTRACTIV............................ATRIC DAY HOSNON-PHARMACESSMENT .............IATIVE CARE IN DEVICES IN PAT
Y ASSESSMENT .NTAGES AND FEGRAMMES IN BERSING IN BELGIRSING IN BELGISYSTEM AND SOGS ....................... MEASURING TH............................EDICATIONS .....
LGIUM: CURRENR GERIATRIC PARACTICE IN BELG............................
STEM ON HEALT............................CER-PHASE 2:DE............................
T-BEDS ................UALITY OF TWO............................
G: OPPORTUNITID PHYSICAL AND............................
ATMENT AND ORVE: ENCOURAGI............................
SPITAL .................EUTICAL INTERV............................BELGIUM ...........
TIENTS WITH OR............................
EASIBILITY OF THELGIUM ...............IUM .....................IUM .....................OCIOECONOMIC............................
HE PERFORMAN........................................................
NT SITUATION ANATIENTS IN CLASGIUM: STATUS Q............................
TH CARE CONSU............................EVELOPMENT A........................................................ FINANCING SYS............................IES AND LIMITS D REHABILITATI............................
RGANIZATION OFING GP ATTRAC........................................................VENTIONS FOR A........................................................RAL ANTICOAGU............................HE INTRODUCTI....................................................................................
C DIFFERENCES ............................CE OF THE BEL........................................................
ND CHALLENGESSSIC HOSPITAL .QUO OR ............................
UMPTION AND ............................ND TESTING ........................................................STEMS ........................................................ON ............................
F CARE ................CTION
............................
............................ALZHEIMER’S ........................................................
ULATION: ............................ON OF ....................................................................................IN THE ............................GIAN ........................................................
3
S . 59 .... 60
.... 61
.... 62
.... 62
.... 63
.... 64
.... 64
.... 65
.... 65
.... 66
.... 67
.... 67
.... 68
.... 69
.... 70
.... 70
.... 72
.... 73
.... 73
.... 74
4
2.2.2.2.
2.
2.2.2.2.2.2.
2.2.
2.2.
3.
3.3.
3.
29. EMERGEN30. THE BELG31. CARDIAC32. ORGANIZ
PERSISTE33. MENTAL H
“THERAPE34. QUALITY 35. QUALITY 36. PHARMAC37. DEMENTI38. DIAGNOS39. ENTITLEM
ILLNESS O40. RESIDENT41. ORGANIZ
STUDY O42. AFTER-HO43. THE ORG
ADOLESCSYSTEMAAPPRAISA
1. LIST OF A2. METHODS
3.2.1. S3.2.2. A3.2.3. D
3. SEARCH 3.3.1. S3.3.2. R
Chronic care
NCY PSYCHIATRGIAN HEALTH SY REHABILITATIO
ZATION OF MENTENT MENTAL ILLHEALTH CARE REUTIC PROJECTINDICATORS IN INDICATORS IN
COLOGICAL PREA: WHICH NON-P
SIS AND TREATMMENT TO A HOSPOR HANDICAP ...TIAL CARE FOR
ZATION OF CHILDF LITERATURE AOURS PRIMARY
GANIZATION OF MCENTS IN BELGIUATIC REVIEW: MAL AND TABLES
ABBREVIATIONSS ..........................
Search strategies .Assessing methodData extraction .....RESULTS ...........
Systematic reviewsRandomised contr
e
RIC CARE FOR CYSTEM IN 2010 ..
ON: CLINICAL EFFTAL HEALTH CARLNESS. WHAT ISREFORMS: EVALTS” .......................
ONCOLOGY: TEONCOLOGY: BR
EVENTION OF FRPHARMACOLOG
MENT OF VARICOPITAL INSURANC............................OLDER PERSON
D AND ADOLESCAND AN INTERNACARE: WHICH S
MENTAL HEALTHUM: DEVELOPMETHODOLOGY,
S OF EVIDENCE FOR THE SYST........................................................ological quality an........................................................s ..........................rolled trials ...........
CHILDREN AND A............................FECTIVENESS ARE FOR PERSON THE EVIDENCEUATION RESEAR............................
ESTIS CANCER ..REAST CANCER .RAGILITY FRACT
GICAL INTERVENOSE VEINS IN THCE FOR PERSON............................NS IN BELGIUM: CENT MENTAL HATIONAL OVERV
SOLUTIONS? ......H SERVICES FORENT OF A POLICRESULTS BY DI............................EMATIC REVIEW........................................................nd risk of bias ......................................................................................................................
ADOLESCENTS .............................
AND UTILIZATIONNS WITH SEVER
E? .........................RCH OF ....................................................................................TURES IN BELGI
NTIONS ................HE LEGS .............NS WITH A CHRO............................PROJECTIONS EALTH CARE:
VIEW ...............................................R CHILDREN AN
CY SCENARIO ....ISEASE, QUALIT............................
W ..............................................................................................................................................................................................................................
KCE Report 1
............................
............................N IN BELGIUM ....
RE AND ............................
............................
............................
............................UM ..............................................................................ONIC ............................2011-2025 ..........
............................
............................D ............................
TY ............................................................................................................................................................................................................................................................
192S
.... 75
.... 75
.... 76
.... 76
.... 77
.... 78
.... 78
.... 79
.... 80
.... 80
.... 81
.... 81
.... 82
.... 82
.... 83
.... 85
.... 85
.... 86
.... 86
.... 86
.... 87
.... 87
.... 87
.... 89
KCE Reports 19
92S
3.
3.
4.
4.
4.
4. RESULTS3.4.1. In3.4.2. A3.4.3. C3.4.4. D3.4.5. H3.4.6. H3.4.7. A3.4.8. S3.4.9. Ir3.4.10. K3.4.11. C3.4.12. P3.4.13. F3.4.14. M3.4.15. C3.4.16. C3.4.17. S
5. SEARCH 3.5.1. Q3.5.2. D3.5.3. Q3.5.4. D3.5.5. SORGANISSTRUCTU
1. STAKEHO(MICRO A
2. STAKEHO(MACRO L
Chronic care
S : EFFECTIVENEnterventions for chAsthma .................COPD ...................Diabetes ...............Heart failure ..........Hypertension ........Angina ..................Stroke ...................rritable bowel syndKidney disease .....Chronic pain .........Painful musculoskeFibromyalgia .........Multiple sclerosis ..Chronic fatigue synChronic neurologicSchizophrenia .......STRATEGY, QUA
Quality appraisal foData extraction tabQuality appraisal foData extraction tabSearch Strategy ....SATION OF CHROURES/PROGRAMOLDERS CONSULAND MESO LEVEOLDERS CONSULLEVEL) ................
e
ESS OF PATIENThronic disease in ....................................................................................................................................................................................................drome (IBS) ................................................................eletal conditions (........................................................ndrome/myalgic ecal conditions - fat............................ALITY APPRAISAor included systemble of included sysor included RCTsble of included RC............................ONIC CARE IN B
MMES ..................LTED DURING BL) ........................LTED DURING S............................
T EMPOWERMENgeneral .......................................................................................................................................................................................................................................................................................................(including rheuma........................................................
encephalomyelitis tigue ................................................
AL AND DATA EVmatic reviews ......stematic reviews . ............................
CTs ...................................................
BELGIUM: SWOT ............................RAINSTORMING............................TAKEHOLDERS ............................
NT : ANALYSIS BY....................................................................................................................................................................................................................................................................................................................
atic diseases and a........................................................(CFS/ME) ..........
............................
............................VIDENCE TABLES............................................................................................................................................ANALYSIS AND
............................G SESSIONS ............................GROUP MEETIN
............................
Y DISEASE ............................................................................................................................................................................................................................................................................................................................arthritis) ..........................................................................................................................................................S ......................................................................................................................................................................
D COORDINATION............................
............................NGS ............................
5
.... 91
.... 91
.... 92
.... 94
.... 96
.... 98
.... 99
.. 100
.. 100
.. 101
.. 102
.. 103
.. 103
.. 104
.. 105
.. 106
.. 106
.. 107
.. 108
.. 108
.. 113
.. 144
.. 151
.. 175 N .. 183
.. 183
.. 186
6
LIST OF F
FIGURES
4.
4.
4.
FiFiFi
3. OVERVIEWSTAKEHO4.3.1. R
c4.3.2. R4.3.3. R
h4.3.4. R
c4.3.5. R4.3.6. R4.3.7. R
re4.3.8. R
a4.3.9. R4.3.10. R
le4. THE ADAP
FROM TH5. BELGIAN
4.5.1. B4.5.2. B
gure 1 – Chronic gure 2 – Results ogure 3: Results of
Chronic care
W OF THE DATAOLDERS GROUP Reform proposal 1enter of a system
Reform proposal 2Reform proposal 3
ospital and homeReform proposal 4hronic health prob
Reform proposal 5Reform proposal 6Reform proposal 7espite care possib
Reform proposal 8nd patient-based
Reform proposal 9Reform proposal 1evels for quality mPTED CHRONIC E BRAINSTORMCOORDINATION
Belgian coordinatioBelgian coordinatio
care model ..........of searches and sf searches and se
e
A COLLECTED DUMEETINGS .......: A polyvalent mu caring for people
2: A case manage3: mid-level scale e care are needed4: the right enviroblem ....................
5: creation of new 6: Specialized hos7: need to clarify tbilities for informa8: moving froma in
payment system9: shared medical
0: aggregated pamanagement purpo
CARE MODEL AMING SESSIONS .N STRUCTURES on structures .......on programmes fi
............................selection of systemelection of RCTs ..
URING THE BRA............................ultidisciplinary prime with chronic career for all patients winitiatives to impro ............................
onment according............................functions at prima
spital functions .....the role of patient l caregivers. ........
ndividual provider ............................file across lines a
atient data at healtose ......................
AND THE RELATI............................AND PROGRAM............................nanced by the NI
............................matic reviews ..................................
AINSTORMING SE............................mary care team ise needs ...............with chronic condiove seamless care............................ to the needs of p............................ary care level ..................................associations and
............................and service-base............................and across disciplth facility and loca............................ON WITH THE TH............................MES ...............................................HDI .....................
............................
............................
............................
KCE Report 1
ESSIONS AND D............................s at the ............................ition(s) .................e between ............................
people with ....................................................................................
d to offer ............................
ed to a team ............................ines .....................
al system ............................HEMES ................................................................................................................
............................
............................
............................
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E .. 188
.. 191
.. 194
.. 196
.. 197
.. 202
.. 203
.. 206
.. 209
.. 213
.. 213
.. 216
.. 217
.. 217
.. 219
...... 7
.... 88
.... 90
KCE Reports 19
1. HIGHL– THE
1.1. ObjecThe objective quality of chro(Pennsylvania) of the impleme(Figure 2). Thfrontrunner cousystems to meeThis part addre• What polic
communicaNetherland
• To what eximplementaoutcomes?
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LIGHTS FRCHRONIC
tive and reseaof this part is tonic care in the Nand Canada (Qu
entation of elemhe objective is untries act upon et the needs of pesses the following
cies for improvingable chronic disds, Denmark, Penxtent do these poation of elements?
ROM FOURC CARE MO
rch questionso describe the pNetherlands, Denebec) and to coments of the Chroto understand tthe challenge o
eople with chronic g two research qug the quality of cseases are beinnsylvania and Quolicies aim to ands of the CCM an
R COUNTRODEL IN US
olicies for improvnmark, the United
mpare the policies onic Care Modehe ways in wh
of redesigning heconditions.
uestions: care for people wng implemented uebec? d/or have resultend with which im
Chronic car
IES SE
ving the d States in terms l (CCM) ich four
ealthcare
with non in the
ed in the mpact on
F
1TodpFCcaepDs
e
Figure 1 – Chron
1.2. MethodsThis cross-sectionof methods anddocuments and pprograms (DMPs)First Dr. Ed WagnCambridge) were compare, Criteria a country of state executing the poprogress in redeDenmark, The Nestate of Pennsylv
ic care model
s nal research is a sources includpersonal commu. er (MacColl Institconsulted for the for selecting largwide policy plan, licy plan, and th
esigning chronic etherlands, the prvania in the Unite
scoping study bading literature (Mnications about
ute, Seattle) and selection of the p
e scale changes the allocation of
he presence of care. Both reco
rovince of Quebeed States as bei
ased on a combinMedline), governdisease manage
Dr. Ellen Nolte (Rpolicies or countrwere: the presenfinancial resourcereports regarding
ommended to inec in Canada, aning good exampl
7
nation nment ement
RAND ies to
nce of es for g the clude d the es of
8
countries or stacare for people Table 1 showscountry. Per cregarding policior scientific reseThis work mainsystem 1,2. Thisthe quality of caimplemented (Pennsylvania),framework deswill need to sareas: data-shaimproving healt2). Experts wecountry they res
ates where largewith chronic cond the used termincountry three exies in their countrearch. ly relies on the fras framework is usare for people witin the Nether
, and Canada cribes that improystematically cooaring for performath care delivery, aere asked to proside.
e scale changes ditions. ology regarding t
xperts were conry. Their backgrou
amework of creatsed to describe tth non communicrlands, Denmark(Quebec) (1st re
ovement strategieordinate actions ance measuremeand aligning bene
ovide feedback o
take place regard
the search for pasulted for the l
und was policy, m
ing a regional heathe policies for imcable chronic disek, the United esearch question
es regarding chroacross multiple
ent, engaging conefits and financeson the description
Chronic care
ding the
apers by iterature
medicine,
alth care mproving eases as
States n). This nic care strategy
nsumers, s (Figure n of the
F
IninoeC
e
Figure 2 – Frame
n order to assess n the implementaoutcomes (2nd reseexisting usage of tChronic Illness Ca
work for creating
to what extent thation of elements earch question), tthe elements of th
are Version 3.5, ar
g a regional heal
ese policies aim tof the CCM and
the CCM is used (he CCM, as descrre applied 1.
KCE Report 1
lthcare system
to and/or have res with which impa(Figure 1). For thiribed in Assessme
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sulted act on s, the ent of
KCE Reports 19
Table 1 – Over
Terms that synonyms which) were usas subjheadings andtext words
“Chronic caremanagement” care" OR orgacountry
*Only studies fromOnly Dutch and E
Figure 3 showoverview regareach country hliterature the Gwebsites led to
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rall term chronic Synonym
appr
(or of
sed ject d/or
Chronic car
Disease ma
Integrated c
Programmaapproach
OrganizatioChronic manageme
e" AND (“ChroOR “Programm
anization OR “C
m 2008 until now arEnglish written articl
s which search sding research stu
have been added Governmental we
other papers amo
care: search Oums for the roach
re model Ne
anagement De
care Pe
atic Qu
on care
ent
onic care modematic approach”Chronic care ma
re included les and papers are
strategies have budies and grey lit(available upon
ebsites have beeong disease mana
utcomes by counSpecified by
country
etherlands
enmark
ennsylvania (USA
uebec (Canada)
el” OR “Disease” OR "integratednagement”) AND
included
been used to recterature. The strarequest). Within tn used as basisagement initiative
Chronic car
ntry*
A)
e d D
ceive an ategy for the grey
s. These s.
F
e
Figure 3 – Overvi
iew of strategiess for literature se
earch
9
10
1.3. Main cBackground infnumber of resihealthcare; typsupplementary
Table 2 – BackCharacteristi
c
Number of residents (year)
% GNP for health care (year)
Type of health care system
characteristics formation regardindents; percentag
pe of healthcareinsurance (see ta
kground data of cThe
Netherlands 3-6
D
16.7 million (2011)
5(2
9% (2008), around 14% (2010)
9
National health insurance system
Nhinspfilonta
of the countrieng the four countre gross national
e system; basic able 2).
countries and thDenmark 7-9 Pe
n
5.5 million 2011)
12(20
9% (2007) 15(20
National health nsurance system, public, nanced by ocal and national axes
Mecains-pamecaPrdoovHefacmaowopprise
es ries are first summproduct (GNP) sinsurance sche
heir healthcare syennsylva
nia (USA) 10
Qu(Can
2.6 million 009)
8,0 (2010
5% in USA 008)
10% Cana(2008
edical are- health surance;
directly ay for the edical
are. rivate is ominant ver public. ealth care cilities ainly wned and perated by ivate
ector.
Univecovemedinecehealtserviprovithe bneed
Chronic care
marized: spent on me and
ystems uebec nada) 11,
12
million 0)
in ada 8)
ersal rage for ically
essary th care ces ided on basis of
d.
C
BIns
Sa
e
Characteristic N
Basic nsurance scheme
Mbain
Supplementary
Vosu
The Netherland
s 3-6
Den
andatory asic health surance
Rolegoveis regusupefinan
oluntary upplement
Reiment
nmark 7-9 Pennnia (
e ernment
mainly ulate, ervise nce
DifferTypeInsurcoverServiplansHMOHealtMaintOrgaPrefeProviOrga(PPOMedicFedeprogrthat indivi≥ 65somedisabindiviMedicProgrthe incomdisab
mbursemlevel and
Healtcentr
KCE Report 1
nsylva(USA) 10
Queb(Canad
12
rent s of ance rage: ce
s, O: th tenanc nizat°
erred der nizat°
O). care2 - ral ram covers duals
5y, and e bled duals. caid3 - ram for
low-me and bled.
Medicarfunded health system,interlockset of ten provinceand three territoriehealth insurancplans. Medicardesigneensure all resihave reasonaaccess medicalnecessahospitalphysiciaservicesa prbasis
th es:
System provides
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bec da) 11,
re –
care , king
the
es, the
es in
ce
re – ed to
that dents
able to
lly ary l and an s, on epaid
s
KCE Reports 19
Characteristic
insurance scheme
1.4. The NThe findings foquality of care summarised inhealthcare systare further desc
Figure 4 – Frathe NetherlandStakeholder C
Shared Data &
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The Netherland
s 3-6
D
ary insurance packages (additional costs)
sathnbDRdpa
Netherlands or the Netherland
for people with Figure 4 accordin
tem. The findings cribed in more det
amework for creds ollaboration: sha
MinistryStakehPatientCare PHealth compa
& Performance MVisible Informa
Denmark 7-9 Pen
salaries are agreed hrough negotiations between Danish Regions and different professional associations
primedeforSea sscbaabpa
s regarding the pnon communicab
ng to the Framewofor each of the e
tail.
eating a Regiona
ared vision and ly of Health
holders ts
Providers Insuranc
nies
easurement Care
ation systems
ennsylvania (USA)
10
Qu(Can
imary edical and ental care r all. ervices on sliding fee
cale – ased on bility to ay.
acceunivecompve cfor mnecehospphysservi
policies for improble chronic diseaork for creating a lements of the fra
al Healthcare Sy
leadership
ce
s:
Chronic car
uebec nada) 11,
12
ss to ersal, prehensicoverage medically essary pital and sician ces
oving the ases are regional
amework
ystem in
ECSInpD
O
F
e
Engaging Consumers Self-management ndividual treatplan DIEP
Outcomes
Future Actions
KIS/HIS)Quality of Vital healt Improvin
Dcare
tment StandardsCare grouDisease chronic diAt one lev
ProgrammSelf-manaKIS/HIS StandardsCare grouBundled chronic caHealth insFinancial
DISMEVAof chevaluationEvaluatingimplemendisease mharmonizemechanisbundled p
f integrated care th
ng Healthcare Delivery s for care ups
management seases
vel
matic approach agement/care
s of care ups
payment of are surers incentives
AL – validation hronic care ns g the
ntation of management e pricing ms with
payment
Aligning FinanInsurance
Bundled paymechronic care Feedback towhealth insurcompanies Financial incentivIntegrated diacare
11
ce &
ent of
wards rance
ves betes
12
1.4.1. Stakeh
1.4.1.1. Miniscare
Given the lack othe number of started to redesquality of carechronic care dapproach for chfor various phaapproach is a based care, wprogrammatic organizing careproviders work demand of careis the individuathe patient to his/her treatmeIn 2008 two insgenerate a cultare quality mFurthermore, prevention andintegrated caredecision supposustainable chrThe Dutch Miimprove the levin the delivery number of comof patients and adaptations of the collaboratinthe delivery sys
holder Collabora
stry of health: pro
of coordination in people in need fsign the healthca
e for chronic disedelivery. This wahronic care, whichases of treatment
program of prewhich are compon
approach, the e. Medical practit
together as onee for every patienal health plan for know which carent through self-mastruments were inture of change ameasures and buself-managementd cure are rega 16. Next, improveort are in need ronic care. nistry of Health
vel of communicatof chronic care.
mplications, hospita less expensiveseveral health ca
ng level the progrstem needed to o
ation: shared Vis
ogrammatic app
chronic care andfor chronic care 1
are delivery systemeases and to incas done by introh aims to offer ant of patients with
evention, self-manents derived fropatient is regartioners, nurses, d
e team. The teamnt. Essential for ththe patient. Next e to expect and anagement 14. ntroduced to tacklmong stakeholderundled payment t and a strongarded as essentiements in clinical
for improvemen
expects the protion between heal This should res
tal visits, improve health care systeare legislations nerammatic approacoccur. Therefore c
sion & Leadershi
proach for integr
d the expected inc13, the Dutch govm in 2008 to impcrease the integroducing a progran integrated care ph a chronic diseanagement and e
om the CCM. Wirded as the cedieticians and othm adjusts the suphe functioning of t
to this, the plan to get more inv
e existing barriers. These two inst
of integrated cg coordination bial for patient cinformation syste
nt 5 in order to
ogrammatic apprlthcare providers sult in a decreasment in the qualiem. Correspondineed to occur 17. Tch describes a chcare groups, stan
Chronic care
ip
rated
crease in vernment rove the ration of ammatic package se. This
evidence ithin the ntre for her care pply and the team enables olved in
rs and to truments care 15. between
centered, ems and o deliver
roach to involved e in the ty of life
ng to this To meet hange in dards of
csNmPpd
1Accsecppcagdsgc
1BhfiNinocPres
e
care and practicestarted. The intrNetherlands is ormost attention. APulmonary Diseasphase. The carediseases, such as
1.4.1.2. Local GA crucial role is collaboration betwcommon and parstimulated to introdenvironment 18. Tcollaboration andprimary care andpeople will becomchange has on absenteeism and government healtdevelopment of aseen as a necesgovernment is regcontinuity of care.
1.4.1.3. ExamplBy means of orgahas been supportinancially stimulaNetherlands Organn order to gain eorganization of chchronic care is PICASSO COPDesearch institute
since 2010. In a la
e supporters in oduction of poliriented towards sAlso, the care se (COPD) and within the progdementia, is awa
Government accredited to th
ween cure and prert of regulated hduce a more integhe national gove integration betw occupational he
me more conscioimproving their on occupational h is the respons
a well organized ssity for chronic garded responsibl
les anizing national coting the debate oated various expnization for Health
experience and inhronic acre delivea collaboration
D (an initiative oCaphri) and the s
ater stage the proj
general medical cies to implemesingle disease wfor people with vascular risk ar
grammatic approaiting to get in prog
he local governmevention. Preventiohealth care. Thegrated health care
ernment would likween the Municealth services. Thousness what kin
health, on prevreintegration. Acc
sibility of individuand integrated pcare managemele for this cohesio
onferences the Duon chronic care
perimental prograh Research and Dnformation on howery. The program of the Ministry of Pfizer, Boehrsection health foujects New Instrum
KCE Report 1
practices have ent the CCM in
with diabetes attraChronic Obstru
re in a reorganizoach of other chgress.
ment to reinforceon needs to be a
e local governmee policy; i.e. a heake to see an imprcipal Health Servhe expectation isnd of impact behvention of workcording to the na
ual citizens 18. Fuprimary care settint 18. Again the on in coordination
utch Ministry of Hredesign. Also, i
ams, directed byDevelopment (Zonw to best improvdisease manageof Health, ICTRringer Ingelheim ndations which st
ments in health ca
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been n the acting uctive zation hronic
e the more
ent is althier roved vices, s that havior kplace ational urther ing is local
n and
Health t has
y The nMw), ve the ement Regie,
and tarted
are (in
KCE Reports 19
Dutch: Nieuweadded. The prwithin the Nethperspective 19. The national gcare’, protocolsincluding qualityof integrated dstandard of vaDutch: Vitale integrated care
1.4.2. Shared
1.4.2.1. VisibThe programmDutch healthcaZorg), a prografrom the Ministrvarious diseasindicators, repreis expected to datasets. This chronic care of improve informas well as betwget developed a
1.4.2.2. InformTogether with ‘improving healand implementproducing relevmade betweenpractitioner infosystems, while
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Instrumenten inroject focuses onherlands and is
overnment also ss for the organizy measures. Examdiabetes care byascular risk manaVaten) 20, 21 anfor people with C
d Data & Perform
le Care matic approach is are system. Theram of the Healthcry of Health, has ses. These dataesenting a level oachieve. Organizprovisional minimvisible care. In otation exchange b
ween care provideand implemented
mation systems:the developmentlthcare delivery’, ted to support thvant data to taken integrated careormation systemthe integrated ca
n de Gezondheidn innovative medaiming to show
supports the evozation and collabmples are the devy the National Dagement by the d the developm
COPD 22, 23.
mance Measure
aiming at morerefore, Visible Ccare Inspectorate,developed so calasets consist oof quality of care zations have to emum dataset 24 isther words, the aibetween organizaers themselves 14
is subject of deba
: KIS/HIS t of care groups, information systehe integrated ca
e informed decisioe information sys
ms (HIS) 25. Theare information sy
dszorg (NIG)) havdical technology
results from a
olvement of ‘standboration in primavelopment of the sDiabetes Federat
platform Vital Vent of the stand
ement
transparency ware (in Dutch: Z, acting upon instled minimum data
of process or oa healthcare organter their data ins part of the dosm is to use the da
ations and health . The way these date.
described in suems are being dere system by mons. A distinctionstems (KIS) and e latter are stanystem does allow
Chronic car
ve been devices different
dards of ary care, standard tion, the
Veins (in dard for
ithin the Zichtbare tructions asets for outcome anization to these ssiers of ataset to insurers datasets
bsection eveloped
means of n can be
general d alone (partial)
ep
1TbDhpddcnlaUfowoeMs
1Vctoindrein
e
exchange of data patients.
1.4.2.3. Quality The program Integbeen launched bDevelopment, actihow this will influprogram 15 projedifferent areas ofdiabetes care. Thcare group is a conurses specified inater on. This careUntil 2012 the bunor Public Health aworking with the bof an effect evaluaevaluation 26. In Minister regardingsystem for the futu
1.4.2.4. ExamplVitalHealth is thecurrently one of tho exchange informntegrated care. Tdossier (EPD). Duesistance. On onformation, on the
among various he
of integrated cagrated diabetes c
by Netherlands Oing upon the instr
uence the multi dects have started f the Netherlande health insurers ollaboration of gen diabetic and oth group is responsndled payment isand the Environmbundled payment ation, evaluation o2012 a National
g the opportunitieure.
les first KIS supplie
he few communicmation between cThe Netherlands uring the launch one hand there e other hand there
ealthcare provide
are care (in Dutch: KeOrganisation for ructions of the Midisciplinary collab
to experiment ws to work with make a deal wit
eneral practitionerher health care prosible for good paties experimental 14. ent (RIVM) has bdiabetes care. Th
of costs of diabetEvaluation Com
es and/or weakne
er in the Nethercation standards wcare providers invois lacking a natioof the system thwere problems
e was ethical resis
rs and sometimes
etenzorg DiabetesHealth Researchinistry of Health toboration 16. Withinwith integrated cathe bundled pay
th the care grouprs, practice suppooviders as is explent care. The National Ins
een invited to evahis evaluation cones care and a pro
mmittee will advisesses of this pay
lands. This systewhich make it posolved in the deliveonal electronic p
here has been a with digitalizing
stance 18.
13
s also
s) has h and o see n this are in yment p. The orters, ained
stitute aluate nsists ocess e the yment
em is ssible ery of atient lot of
g the
14
1.4.3. Engag
1.4.3.1. Self-mFor the Dutch programmatic agreat impact oown life, it is beinto their life. active, to searcother words thaddition, to be need to masterTherefore, profthis role 18.
1.4.3.2. IndiviAs part of the contact within fragmentation fteam of care prconsists of the belonging carepersonal needs
1.4.3.3. ExamDIEP One of the beNetherlands is tself-managememanagement, providers 27,28. aiming at streincreasing the instructions of t(NDF).
ging Consumers
management/CaMinistry of Healt
approach. Peoplen their own healtelieved that chronSelf-managemen
ch for solutions ane patient and the able support ser different compefessionals need a
idual treatment pprogrammatic apthe care syste
for patients. The roviders together care the patient
e provider. The ts and wishes and
mples
est known projecthe diabetes inter
ent program whicto educate peopAlso the Nationangthening the ro
quality of self-the Ministry of he
are th self-manageme with a chronic dith. By having thenically ill patients t stimulates the nd to work togethe care providers elf-management ietencies to becomadditional educati
plan pproach, the patieem in order to idea behind thisdefine an individneeds to receive
treatment plan shshould consist of
cts focusing on ractive education h is used as a suple with type 2 al Diabetic Actionole of the patienmanagement ed
ealth and the Nati
ent is a key worisease are able toe ability to influenare able to fit thechronic ill patien
her with care provwill become partn patient, care p
me a partner for pon to be able to
ent will have oneminimize the
s plan is that patual treatment plae in combination hould fit to the measurable targe
self-managemenprogram (DIEP). Tupportive methoddiabetes and th
n program (2009-2nt through educaucation and traional Diabetes Fe
Chronic care
rd in the o have a nce their ir illness nt to be viders. In tners. In
providers patients. take on
e central level of ient and n, which with the patient’s ets 14.
t in the This is a
d of self-eir care 2013) is ation, at ning on
ederation
ACpimCebp
1TbtrcthpreFpinmItthcli
1InpdqthcMaw
e
Another example Consumer Federapatient organizatiomplementation ofCare (CBO). The embedding the chbased tools areprofessionals. 18.
1.4.4. ImprovingThe programmatbetween care prreatment protococontact person forhe patient and ispractice supporteresponsibilities in o
Further, in order toproviders, the orncreased to enamanage the popult is expected thathe growth of thecomplications andfe will be improve
1.4.4.1. Standarn 2009 the Healpayment would bediseases as of 1question are crucihe Dutch Healthcoordinating platfoMinistry of Healthapproach and havwith chronic dise
is the self-manaation (NPCF), whons and care prof the program is daim of the progr
hronic disease in being develop
g Healthcare Deic approach is roviders and to l for patients. Onr a patient. This ps often being per 14. This requires order to be able too assess and furtrganizational streble care provideation of people wt through effectivee number of peod co-morbidity willed, and the patien
rds of care lth Minister annoe introduced on January 2010. al to introduce bu
hcare Authority (Norm Standards o 26. Care standa
ve as main aim toases 18. The me
agement programhich is launched ofessionals both done by the Quaram is to enhancea patient’s life. T
ped for patients
elivery expected to senable discuss
ne care provider operson coordinatesrformed by the gcare providers to
o work as a team.ther improve the qength of primaryers to act pro-acith chronic diseasely implementing ple with chronic l be prevented ort is able to manag
ounced to the Paa permanent basStandards of ca
undled payment, aNZa, 2009b). Zo
of care, acting uprds are the baseo improve the quaeasures are base
KCE Report 1
m of the Dutch Pin 2009 and witas target group
ality Institute for He the quality of li
To reach this aim and supportive
timulate collaborsions about the of the team serves the individual cageneral practition
o define their tasks. quality of care fory care needs tctively and to acses. disease managemdiseases will re
r postponed, quage its own health
arliament that busis for several chare for the diseaa standpoint shareonMw has startedpon instructions oe for the programality of care for ped on guidelines
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atient h the . The
Health ife by web-
e for
ration best
es as are of ner or s and
r care to be ctually
ment, duce, lity of 14.
ndled hronic se in ed by d the of the matic eople
s and
KCE Reports 19
consensus andhas to adhere, of care include disease, the orindicators. A geprovides for evedisease-specifica patient, whichsupport a patieideas about orgEvery Standardproviders. Theexpectations oFurthermore, tpayment of inteincentives. Theyet, although dpace. Furthermchronic diseaseNowadays the diabetes foundplatform vital vNetherlandsc.
1.4.4.2. Care In order to delunite into so cprimary care prthe care insuremeans that a patients with dia
a http://www.b http://www.c http://www.
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describe to whicseen from the pethree main parts
rganization of preeneral model for cery chronic diseac part. Furthermoh role a patient haent can expect. Iganizing and strucd of care consists ese standards aof people with hese Standards egrated care as mese Standards of evelopments in p
more multi morbides, pleads for a intStandards of caredation of the Nveinsb and COPD
groups iver high quality
called care grouproviders in a particers by means oprocess is negotabetes, COPD or
dvn.nl/over-dvn/organvitalevaten.nl/home.hastmafonds.nl/samen
ch requirements cerspective of the : prevention and vention and care
care standards hase a framework,
ore, it describes was in its treatment In addition, the ccturing care 18, 23.of a part for the p
are actualized rea chronic illneof care are the
mentioned in the care do not exis
practice settings adity, which is oftetegrated approache are implementeetherlandsa, vasD, part of the A
chronic care, caps. These care gcular region who cf a bundled paytiated for the delvascular risk.
nisatie/producten/diabtml
n-de-zorg-verbeteren/z
care for a specific patient 23. The Stcare for a certain, and the relevan
as been developeincluding a gener
which care availabprocess and wha
care standard co
patient and a part egularly as wishess change coe base for the next paragraph,
st for all chronic dare proceeding aten seen in patieh of care standardd for diabetes, pacular risk mana
Asthma foundation
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yment arrangemeivery of chronic
etes-zorgwijzer
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Chronic car
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ral and a ble is for at kind of uld give
for care hes and nstantly. bundled financial
diseases t a rapid
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1.4.4.3. ExamplDisease managemn 2008, the natidisease managemguided by Vilans diseases of ZonMparticipate. This prorganizations andmproved 29. Part or more componexperiment are exAt one level Another example approach started 2009 until 2013consolidation throun line with the pstated. This shouconditions and caattention is on six
1.4.5. Aligning F
1.4.5.1. BundledThe Dutch governThis implies that awith an insurance complete treatmenway the bundled nstead of everyobundled payment
les ment chronic disonal government
ment initiatives in as part of the p
Mw until April 20roject is aiming tod with this how of this scientific e
nents of the chxpected to be pres
is the program ‘Aby ZonMw on in
3 30. The progrugh innovation anprogrammatic apuld result in impre at home and tchronic diseases
Finance & Insura
d payment of chment has started a contractor (i.e. company. The S
nt of a patient popayment stimulatone having differregime for care gr
seases t assigned ZonMthe Netherlands.
program Disease 12. More than tw
o bring together excare of chronic
experiment is the ronic care mode
sented in 2012.
At one level’ (in Dunstructions of theram aims to snd entrepreneurshproach as the Mroved synchronizthe care demand and care of the e
rance
ronic care with a new paymcare group) mak
Standard of care isopulation for a ctes the care provrent financial incroups was implem
Mw to experiment. The care group
management chwenty care groupxpertise within diff
ill patients coulimplementation oel. Results from
utch: Op een lijn)e Ministry of heasupport organizahip of the primary
Ministry of Healthzation between h
of the locals. Spelderly.
ment system in 20kes a stable prices used as base fo
certain disease. Inviders to work togcentives. In 2010mented nationally.
15
t with ps are hronic ps do ferent ld be
of one m this
. This alth in ational y care h has health pecific
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16
1.4.5.2. FeedBased on med(IGZ) has devresembles the Qincludes multidand performancrucial role indevelopment of
1.4.5.3. FinanTo stimulate ththe delivery oresources for psuch as generaundertake innoincentives the csupporter in gepractitioner and
1.4.5.4. ExamIntegrated diabThe program evaluate the intThis experimengroups in orderpayment 26. ThiHealth and the bundled paymeby a NationalFurthermore, inas aim to stimu
dback towards Hical guidelines an
veloped indicatorQuality and Outco
disciplinary evidence indicators. Asn chronic care f quality indicators
ncial incentives he development oof chronic care, practice innovational practitioners, arovative interventiocare providers areeneral practices, td to make the prim
mples betes care Integrated diabe
troduction of bundnt provide a financr to contract integris pilot is being ev Environment (RI
ents for chronic c Committee, wit
n the drafted law late the empower
Health Insurancend standards, thers to assess heomes Frameworknce based guides the empowermmanagement the
s 5.
of necessary strucspecific financia
n) are developede able to apply fo
ons for chronic pe for example ablto lower the work
mary care more str
etes care, initiatedled payments forcial incentive to a rated diabetes cavaluated by the NIVM) (see ‘outcom
care in the Netherth results becom‘client and quality
rment of the indivi
companies e Healthcare Inspalth care quality
k of the United Kinelines, process pment of patients ey are involved
ctures and proceal incentives (so. Primary care pr
or these when theypatients 5. Througle to employee a k pressure of the ructured.
ed by ZonMw, r integrated diabetrestricted numbere by means of a ational Institute fo
mes’). The introdurlands is being evming available iny of care’ seems dual patient.
Chronic care
pectorate y, which ngdom It protocols
plays a in the
esses for o called roviders, y plan to gh these practice general
aims to tes care. r of care bundled
or Public uction of valuated n 2012. to have
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1.4.6. OutcomeThe chronic careoadmap to improntegrated mannerdifferent approachsee above). Give
care is ongoing, on
1.4.6.1. ProgramFrom the DISMEVprograms consist ontegrated care aNetherlands does mproved outcomDrewes et al. studmanagement areconcluded that thassociated with imLemmens et al. ths not the only mplemented andLemmens et al. shmplemented inteoutcomes occurredThe Ministry of Hepractice. This proconsists of three digital care progrnformation and esulted in effectiv
www.diabete
es e model is increaove the quality of r. The Ministry of hes into place ann that the developnly preliminary res
mmatic approachVAL study it was of a selection of c
approach 31. Connot seem to be of
mes died if a higher n
e associated withe presence of
mproved outcomese number of cominfluencing varia
d integrated imphowed when bettervention and thed 32. ealth regards the oject is facilitatedmain parts, a st
ram to be followcommunication s
ve and efficient ca
szorgbeter.nl
asingly applied inchronic care andHealth has a cle
nd therefore finanpment and implemsults are known a
h found that diabe
components whichsequently, ‘full’ iffered to patients
number of compoth improved patmultiple compon
s 20. In addition, aponents of the chable. Also how acts the effect er adjustments wee bottlenecks, m
Diabetes care prod by the programtructural multi- diswed by the patiesystem.d The prore on different lev
KCE Report 1
n the Netherlandd its delivery in a ar view how to ge
nces several initiamentation of integat the moment.
etes care manageh make up the CCntegrated care iyet.
onents of chronictient outcomes. nents of the CCaccording to a stuhronic care model
the components22. Another studere made betwee
more positive cha
oject in Zwolle asmmatic approachsciplinary approa
ent and an integogrammatic appr
vels 16.
192S
ds as more
et the atives grated
ement CM or n the
c care They
CM is udy of
used s are dy of en the anges
s best h and ach, a grated roach
KCE Reports 19
Barriers for imThe Dutch natioable to bring ellacking. Also tcollaboration bemay have a nethe uptake of thNext to barrierswhich have notand proactive currently seeingcould take over
1.4.6.2. Self-mDIEP is a projeself-managemeabout the projediabetes. Howeof care provide28. Blanson and Hshort run self-mremain quality osaving for profe
1.4.6.3. KIS/HAs a result of multiple regionato exchange inbarrier to introdproviders to use
92S
mplementation onal healthcare syements of the mothe fragmentary etween care prov
egative impact. Thhe CCM in daily prs there are also a t brought in pract
patient specificg the general medr the role to coord
management/caect for diabetes caent. The results ect as it increasesever, the main barrs to make use o
Henkemans studiemanagement hasof care. On the loessionals in care :
HIS f the political resal systems have bnformation betweduce ICT systemse advanced possi
ystem as such seodel into practice nature of primarviders in differenthird, the tight laboractice 18. few components tice yet, such as
c care. Furthermdical practices as inate total care 18
are are and aims to eof DIEP show th
s self-managemenrrier of the project
of the program as
ed the value of ss the potential to ong term, self-man
33.
sistance against become in use wheen regions and s in primary care bilities of ICT 18.
eems to be a barras various incentry care and the t areas of care aor market might in
of the chronic carICT, coordination
more the governcentre, but also h.
empower patients hat patients are nt and their knowt seems to be lackpart of their activ
self-management.reduce care sup
nagement could b
a national EPD hich make it morecare providers. is the willingness
Chronic car
rier to be tives are
lack of and cure nfluence
re model n of care ment is hospitals
through positive
wledge of k of time vities 27,
On the pply and be labor-
system, e difficult Another
s of care
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1.4.6.4. StandarThe way the care care as mentionedmportance of the he Standards of cNetherlands Orgawas launched 19,2
considered the eanterventions aimeThe Standard of che bundled paymn contradiction wreatment cannot made. Such a divapproach supporcontinuum of careelated prevention
1.4.6.5. Care grGeneral practitionehey should not becare groups, repremultidisciplinary ca
1.4.6.6. BundledThe Dutch mandapolicy excess. All subject to the excewhich services bproblems 18. Furbundled payment These also give pdecided in 2010compulsory excespayment contractsynchronized, ineq
rds of care system is organizd before 6. As thbundled paymen
care, the Standarnisation for Healt26. The impact oarly inclusion of
ed at diminishing rcare for diabetes eent arrangement with one of thebegin until a fo
viding line is serrted by the Mine ranging from ea, self-managemen
roups ers are playing a e the single playeesenting all ‘coreare 17.
d payment of chatory health insu
GP care in the ess, whereas all o
belong to GP cathermore, lookingit seems to be
problems at the p0 to keep the ss. Following frots include the saquities rise among
zed is a barrier to he Ministry of Heant system which sds of Care Coordh Research and Dof this platform patients at risk
risk factors for diaenlists preventive for diabetes. How
e mandatory ruleormal diagnosis oriously at odds wnistry, which enarly detection, indnt towards treatm
dominant role in cers within this groue disciplines’, are
ronic care rance package cbundled paymenother care is. As
are and which dg at the integracontradicting to
payment side. Asbundled care p
om this decisioname componentsg diabetes patient
integrate Standaralth acknowledge
should corresponddination Platform aDevelopment (Zois unknown yet. appropriate to inbetes 18. intervention as p
wever, this seems es, which statesof diabetes has with the programnvisages a comdicated and treatment and care 34.
care groups. Howup, as multidiscipnecessary to pe
contains a compunt arrangements iit is not clearly deo not, this resu
ated character omake this distin
s a result the Mipackages outsiden, as not all bus and this is nots in the Netherlan
17
rds of es the d with at the nMw) GPs
nitiate
part of to be
s that been matic
mplete ment-
wever, plinary erform
ulsory is not efined lts in
of the ction. nister
e the ndled
ot yet nds18.
18
Moreover, the eand the Envirocosts of healthtargets the Mincould possible eOn the other haa possible way condition for intand the increabundled paymeAlso, the financas well as on cbundled paymewhole standardchronic disease18,26. Another ddrawing up the
1.4.6.7. HealtBargaining andbetween individand service prothe evaluationreexamination athe preventive t
1.4.6.8. FinanThe Dutch goveinto the chronisegmented andthese incentivesystem 15. The
1.4.7. SummIn 2008 the Dutin terms of the
evaluation report onment (RIVM) sh care through bunister of Health heven rise 26. and, the evaluatioto cooperatively dtegrated care 26. ased shared respent 18. cial part plays a rocure. The policy aent of chronic careds of care as suche is covered in thdiscussion is the standards 26.
th insurers d the market positdual health care poviders improved t. The Dutch baas the current butreatments in the
ncial incentives ernment has sevec care delivery sd the stability of es have been reeffect of this repla
mary tch Ministry of Heprogrammatic ap
by the National Ishows it is unknoundled payment as set are even
on report indicateddeliver care, whicHowever, the impponsibility repres
ole here as care nand the accompae within the stand
h. Only a patient whis policy, a pers
role insurance c
tion might be a risproviders and caretheir record-keepi
asic health insurndled payment scbasic packages 18
eral financial incesystem. As thesethese incentives eplaced by the aced payment sys
ealth revealed a npproach for chron
Institute for Publicown if savings onschemes will occunlikely to achiev
d that bundled paych might be regardproved process insent the added v
needs to be on preanied finances is cdards of care, butwho is diagnosed son with high riskcompanies might
sk on the market e groups. The heaing habits in the crance packages chemes may not c8.
entives to start inte financial incentare not ensured new integrated pstem is not yet eva
ew vision on chronic care i.e. an in
Chronic care
c Health n macro cur. The ved and
yment is ded as a ndicators value of
evention covering t not the with the
ks is not t play in
integrity alth care course of
need a cover all
tegration ives are in 2010
payment aluated.
onic care tegrated
pcT•
•
•
•
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e
package of varioucure and care) of The programmatic To implemen
introduced onmeasures anCOPD and vaagainst the neighborhood
First attemptsto measure pecare standarregarding dialevel;
Also regardininitial attemppromoted as of patients act
The role of strengthen itsThis is getting
Preliminary rchronically iloutcomes of care are idebetween provthe Chronic Cof care, proac
s phases (prevena continuum of c
c approach is derivnt the programmn a national lev
nd bundled paymascular risk mana
vision of redds including an ims are made to collerformance. Notwrds, performanc
abetes manageme
ng the engagemepts are being mpart of national ctually have such aprimary care re
s activities regardg shape by the devresults regardinglness show mocare. Also, barrie
entified (e.g. lackviders, fragmenteCare Model whichctive patients).
ntion, self-managecare for patient wved from the Chro
matic approach tvel by the Minisments of integrateagement. Local inesigning chronicportant role for prlect data in a stan
withstanding the dee measurementent on an exper
ent of patients wmade: individual care standards, hoa plan; eceives specific ding the organizavelopment of care
g the impact ofodest improvemeers for implementk of incentives, d primary care) a are underdevelo
KCE Report 1
ement, evidence bwith a chronic disonic Care Model; two instruments stry of Health: qed care for diabitiatives are stimuc care within rimary care; ndardized way in evelopment of nats only takes imental base on
ith a chronic distreatment plans
owever only a mi
attention in ordation of chronic e groups. f integrated careents in process ting integrated chlack of collabor
as are componenoped (ICT, coordin
192S
based ease.
were quality betes, ulated
local
order tional place local
ease, s are nority
er to care.
e for and
hronic ration nts of nation
KCE Reports 19
1.5. DenmFramework for
Figure 5 – FraDenmark Stakeholder C
Shared Data &
Engaging Consumers
Patient education classes andincreased self-management Guided Self-Determination
92S
ark creating a Region
amework for cre
ollaboration; shaMinistry National BoardStakeholders Patients Care ProvidersHealth InsuranChronic diseasHealth care cenImplementationrehabilitation p
& Performance MNational IndicaIT support KOALA
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ealthcare Deliver
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al Healthcare Sy
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der range of problems and
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19
rough of
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1.5.1. StakehShared Vision &
1.5.1.1. NatioIn Denmark thexclusively to raim to developbe implementedfor this journeyDistribution tasstronger centrasystem. It detehealthcare areexplicit aim of reports 36-39. The regions mahospitals and Government andevelopment atreatment of ch7,35. This is establishment Practitioners is stakeholders whospitals, genemunicipalities 35
In 2002 the MHealth throughogovernment of document, spediseases and improve the quain terms of coumeasures. In lisick individual w
holder Collabora& Leadership
onal Governmene role of the cenregulate, supervisp national diseased in the existing oy has been takensks are laid dowal control in the ermines the regia 36. The delivethis Act as is als
anage somatic anprimary health s
nd the municipalind implementatio
hronic conditions, also a task foof healthcare con several parts
within this approaeral practitioners, 5. inistry of Interior out life – targets a
Denmark 2002-2ecifically focuses disorders. On toality of life of the unseling, supportine with the CCMwith knowledge a
ation
nt ntral Governmentse and finance cae management worganization of hen up by the Nati
wn in the Danishtraditionally high
ional and municery of coordinateso seen in differe
nd psychiatric heaservices. This is ities. The regions
on of overall stratincluding disease
or the municipalcentres 7. The O
supportive of thisach are health and health profe
and Health has and strategies for 2010. The prograon efforts to re
op of that, the apopulation througt, rehabilitation a
M, this program isnd tools to be abl
t in healthcare isare. Denmark haswith local specificaealthcare. The leaional Board of H Health Act to ohly decentralized ipal responsibility
ed health serviceent policy docume
althcare services funded by the
s are responsibletegies for prevente management plities together wOrganization of s development. Tprofessionals wossionals employe
released the dopublic health policam, as describededuce major previm of the progra
gh more systematind other patient-s aiming at provile to promote his/
Chronic care
s almost s set the ations to adership ealth 35. obtain a
Danish y in the es is an ents and
in public national
e for the tion and rograms
with the General
The main orking in ed in the
ocument: cy of the d in this ventable am is to ic efforts -oriented ding the /her own
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health status andherefore a speciaHealth throughoudiabetes; cancer; allergy diseases; pGovernment platfarge initiatives to 2008 the governmield of health economics and reSecondly, the goecommendations
program including
1.5.1.2. Local Gn 2007 a reorganmore healthcare ormation of so cacurrently on prevedisease. The socchronic diseases 4
professionals and expected that grehealthcare sectorntegrated with theA system of mandeplacing the prev
prevention, treatmNational Board of people with chronbeen taken into amanagement supManagement progUSA 7,42 The repoo manage his heasupport to take hi
d health care andal focus on healthut life’-program iheart disease; o
psychological diseform 2007 the Dfollow up on “Hea
ment appointed a promotion and epresentatives froovernment will, o, publish a new clear aims for fut
Government nization of the mu
tasks for the loalled healthcare
ention and rehabilicial services, de41. The GPs are fu
have been a keeater integration rs will occur, w
e social services 3
datory regional hevious health plansment and care 7.
Health putting thnic conditions 7. Iaccount, such as pport program bgram (CDSMP) dort emphasizes thalth condition ands own responsibi
d to not further h-related behaviois on the follow
osteoporosis; museases; and COPD
Danish governmealthy throughout lcommittee considisease prevent
om both the pubn the backgrounpublic health an
ture efforts 38.
nicipalities took pocal government. centres. The focuitative services fo
elivered by municunctioning as a gay feature of the Dbetween the pr
whilst primary h9.
ealth care agreems, to strengthen thIn 2005 a reporte focus on the imIn so doing regio the use of the
based on the Cdeveloped at Stanhat the individual d maintain a life oility and to make
KCE Report 1
lose functions. Ior 40. The focus o
wing diseases: tysculoskeletal diseD 40. As part of thent launched twolife”. Firstly, in Jansting of experts ition program, hlic and private se
nd of the commind disease preve
place, which has lThis resulted in
us of these centrr people with a chcipalities include ate to other healthDanish system 41
rimary and secohealthcare is alr
ments was put in phe coherence bett was released b
mprovement of caonal experiences Chronic Disease
Chronic Disease nford University ipatient should be
on his own and rewell-informed ch
192S
t has of the ype 2 eases; e new new nuary in the health ector. ttee’s
ention
led to n the res is hronic
also hcare . It is ndary ready
place, tween by the re for have Self-Self-
n the e able eceive hoices
KCE Reports 19
43. Following thfocus should beoptions of strenenhances the rprivate organizwithout regard all healthcare pThe interaction to consistency the patients inv
1.5.1.3. ExamChronic diseasThe National Bdisease pathwa2008. This modentire treatmeresponsibility astakeholders. Aneeds to occurNational Board of national diseauthorities. Diabetes mellitpathway descritargeted by theNational Indicatthe pathway implementationdifferent aspecprofessional aimthe best achiev
92S
he recommendatie on the organizangthened and supole of the civil soc
zations et cetera for the social con
providers need tobetween patientsbetween efforts toolved have a unifo
mples se pathway prog
Board of Health hay programs, a fradel is inspired by ent process, eand coordination As this is a natio. This will follow fof Health expects
ease programs in
tus has been septions by the Nat
e systematic qualitor Project (NIP) aprogram these in a certain org
cts of the programm at the same obable results.
ons of the Natioation and provisiopported self-manaciety – the social – given that lifes
ntext in which peoo obtain or posses and healthcare o ensure that theform, common goa
grams has launched a gamework for disethe CCM and inc
evidence-based and communica
onal program, spfrom the implemes to take responsi collaboration wit
elected as pilot tional Board of Heity development iand in the Danishinitiatives shouldganization 36. Asm will be ensuredbjective and the in
nal Board of Heaon of health care agement 36. The networks, the wo
style cannot be cople live. Simultas relevant compeprofessionals shohealth profession
al.
generic model forase specific progludes a descriptiorecommendations
ation among all pecification at locntation process 35
ibility for the deveth regional and m
for the developealth. Diabetes mn general practice Quality Model. Ad be connecteds such coherenced; the patient andndividual program
Chronic car
alth, the and the program
orkplace, changed neously, etencies. ould lead nals and
r chronic grams, in on of the s, task involved cal level 5, 38. The
elopment municipal
ment of mellitus is
e, in the As part of d during e of the d health
m aims at
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Health care centrThis centre coversof chronic condimunicipal hospitalproject ‘Integratedhis project the Genhance integratewith one or more chospitals towards o patients is encooperation. In ad. The project take
management (pprofessionals aremanagement), decare, risk stratificacare pathways, professionals andhealthcare centreand that rehabilitaand hospitalizationmplementation amprovement n the Implementorganizations collmplementation anCOPD, type 2 diapreventing falls imanagement pracchronic condition personal action plplans were defineducation and teaof that teamwork,were used to suorganizations 44.
re Østerbro s different facilitiesitions. The city’s and GP’s work t
d effort for peopleGP is referring thed care pathwayschronic conditionscare in the comm
nsured through tddition, the centrees into account seersonal action e competent tolivery system desation) and decisio
program evalu competencies inwill result in few
ation program migns. and integration
tation and integrlaborate to imprond integration of rabetes, chronic hen elderly people
ctices were implemwere developed
ans were part of ned together w
aching programs w to optimize carepport quality dev
s and therapies tos Health and Sogether to createe with chronic dise patient to the
s and promote res and by this to mamunity. The provisthis interdisciplinae guides the patieeveral aspects of t
plans, patiento support patiesign (coordinationon support (specation, guideline
n place) 37. The ewer hospitalizationght help to preven
of rehabilitation
ration of rehabilitove the quality orehabilitation progeart failure. A fou
e. To support inmented. Also clinid. Furthermore, the program to s
with healthcare pwere integrated ine, and identical pvelopment proce
o patients with a rSocial Administr
e the local chronicseases’ (SIKS). Wcentre. The aim
ehabilitation of paake a shift from casion of integratedary and inter-sent in self-managethe CCM, such ast education, hent with their n of care, team bialist in place, de
training for hexpectation is thans over the long nt disease progre
n programs – qu
tation programs of healthcare thrgrams for patientsurth program aimntegrated care prcal guidelines for self-managementupport patients. Tprofessionals. Pn the program. O
performance measses in and bet
21
range ation,
c care Within
is to tients are in
d care ctoral
ement s self-health
self-based efined health at the
term ession
uality
three rough s with
med at roven each
t and These atient
On top sures tween
22
1.5.2. SharedThe Danish docis not yet sybetween nationstrategy for dig2007 39. Thiimplementationall actors in natof messages, information fropatient medicalrequirements oservice (e.g. isolutions). Eaimplementationand the joint incoordination wipreviously have
1.5.2.1. ExamNational IndicaThe Danish Nmeasures perfohospitals to grocreate awarenhealthcare profoutcomes of thhealthcare seradequate or in health specialexamination of of a patient. From 2000 ofactors have befor eight diseas
d Data & Performcumentation of sestematic and di
nal, regional and gitalization of thes cross-governm of specific actiontional health care
an e-safety sm certain hospital card. All of this of individual playn relation to th
ach actor rema and operation of
nitiatives www.nsiill occur in a fielde largely develope
mples ator Project ational Indicatorormance. It looksoups of patients wness in patientsfessionals about e treatment are u
rvice. The focus need for improveist who is worthe results will be
onwards, quality een developed. Tses some of them
mance Measureervices delivered isease-related 7. municipal author
e Danish healthcamental organizan plans involving ce of several systestandard, an e-al IT-systems acis combined in a
yers in each sege interfaces andins responsible f it all in accordan.dk. Through colld where regions ed their own soluti
r Project (NIP),s at the quality with specific meds, families, doct
the extent to wup to the standard
is on courses ement. The indicarking regularly we performed by all
standards, indThe quality of car
are chronic, such
ement in the primary car
However, collarities launched a are service in De
ation will facilitacommon ICT-solums; system for ex-journal system ccessible for GPsn overall framewogment of the hed functionalities
for the develnce with the natioaboration furtherand general pracions 39.
, established inof care providedical conditions. It tors, nurses anhich the completds from a well-funof treatment wh
ation should be dowith the diseasel healthcare profe
dicators and prre is nowadays mh as COPD, diabe
Chronic care
re sector aboration
national ecember ate the
utions for xchange making
s and a ork, with
ealthcare of local lopment,
onal plan national
ctitioners
n 1999, d by the
aims to d other tion and nctioning hich are one by a es. The essionals
ognostic measured
etes and
haITAsDimdKAfeaereinm
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e
heart failure. Durinalso been developT support Another example sharing informatioDanish health caremplantable cardiodifferent healthcarKOALA A third example iseasibility of introassures quality ofevaluates if theehabilitation is usn 2010 33 healtmedical solutions
1.5.3. EngagingAs part of the reldiseases-specific chronic diseases. stay 7. The natorganizational andof all stakeholdersStanford ChronicThis national progeducation and act3. The process of
consists of a sixacilitated by twobackground and waspects such as cmedication, commreatments. The ssupport and confid
ng 2009 quality inped 45.
is the developmeon between institue system. The prooverter-defibrillatore providers 46.
s the KOALA prooducing a nationf data in the recoe Danish guidesed correctly. The hcare centres wmay introduce ne
g Consumers eased report foceducation classThe aim was to
ional objective d individual, regios 43. c Disease Self-Magram (see above) tive involvement of how the CDSMPx week workshoo trainers, one owith a chronic discoping strategies
munication with thsessions require adence to be able t
ndicators for depr
ent of IT support futes to decrease oject is focusing oor (ICD) as they
oject, which on onnwide web-basedovery programs aelines for comm
program exists frwere involved 47.
w possibilities for
using on the regses have been o reduce hospitalis patient involv
onal and municipa
anagement Progfocuses on the dof patients in moP is taught has b
op given in a coor both without sease. The focus , possible exercishe surrounding aactive participatioto manage on a he
KCE Report 1
ression and birth
for communicationboundaries withi
on chronic patientsy make often us
ne hand assessed tool to recordand on the other munity based Crom 2007 onwardDevelopment of integration 39.
ional support in 2offered, includinizations and leng
vement at all lealities and cooper
gram (CDSMP) disease specific ponitoring and treatbeen found effectommunity centrea health professof the workshop
ses and nutrition,and evaluation ofn and build on mealth life 48, 49.
192S
have
n and n the s with se of
es the and hand
COPD s and tele-
2005, g on
gth of evels, ration
atient tment ive. It
e and sional is on right f new
mutual
KCE Reports 19
Example: guidThis method foDetermination developed to faovercome barrdiabetes by dstakeholders in
1.5.4. ImprovThe main stakeprograms are practitioners, aThe GPs are fuhave been a keintegration betwoccur from disealready integratIt was found thhours a day services that mpointed out in thSharing DecisTo get more icommunicationDecision-MakinFacilitate referThe cross-govethe Danish heaand discharge between practicsharing of elect
92S
ded Self-Determinocuses on self-m(GSD) is used
acilitate problem siers. The aim of
developing life s the process, usin
ving Healthcare eholders within th
health professnd health professunctioning as a g
ey feature of the Dween the primarease managemeted with the sociaat Danish health advising patients
might play a role inhis respect. ion-Making in Chinsight into patie and reflection m
ng in chronic care,rrals and discharernmental organizalthcare service. Sletters, and has
ces while there hatronic medical rec
nation anagement in paby the Steno
solving between pthis project is to
skills. This is reng individual and c
Delivery e implementationsionals working sionals employed
gate to other heaDanish system 41. ry and secondarynt programs, whl services 39. professionals spe
s on lifestyle chn self-managemen
hronic Care ents’ decision mamodel was develo, gaining insight forges zation has starteSo far this has facenabled patient r
ave been legal ancords 39.
atients. The GuidDiabetes centre
patient and professo empower patieeached by guidincommon potential
n of disease manaat hospitals,
d in the municipalthcare professionIt is expected thaty healthcare secilst primary healt
end between 0.5 hanges. Howevent support are no
aking a person-coped. It identifiedor professionals 51
d a strategy to dcilitated use of E-records to be exc
nd technical barrie
Chronic car
ed Self-and is
sional to ents with ng both lity 50, 51.
agement general
alities 35. nals and t greater
ctors will hcare is
and 2.5 er, other t always
centered Shared 1.
digitalize referrals changed ers to full
1TothainneinFTathpbbaFcFfosotoFAcfopaposp3
e
1.5.5. Aligning FThe way the healtof a structural rehrough a combinaand municipality fncrease preventionational incentiveexpenditure. So ncentives are dispFinancial incentivThe fee covered thand is based on the GP in the arepatient follow-up. be checked, whichbetween the diffeand self-managemFinancial incentivcare delivery Financial incentiveor the municipaservices, introducopportunities to sto result in decreaFee for chronic dA financial incentivcare has been creor diabetes patieparticipating and advantage for the progress of their others. Also, a fservices. The ideapatients are offere5, 39.
Finance & Insurathcare system is eformation of coation of a nationaunding (20%). Th
on and through the should contribu
far, no results played below. ves among GPshe different aspeche needs of the ia of program appNonattendance o
h is a new task forrent stakeholders
ment of the patientves for the mun
es for healthcare lities. This cons
ced by the healthtimulate preventivsed hospitalizatio
disease managemve for chronic diseated. Incentives ents 7. An incenti
reporting patieGPs to participatpatients and to cfee has been sa behind this is thaed preventive treat
rance financed has bee
ounties in Denmal kind of health ta
he municipality fuis reduction of houte to a more t
are available 7.
cts of the disease ndividual patient.
propriateness, gooof the patients dur Danish GPs ands in the disease t 7.
nicipalities at the
delivery at the losist of co-financihcare Act, and sve services which n 35.
ment programs inease managemenexist for GPs to ive for GPs has nt data in a ste is that they arecompare their ouet for disease sat it will result in imtment and follow-
en changed as a ark. Financing o
ax (80%), region gnding was intendspitalization ratesransparent health. Some example
management pro This requires mood documentationring the program d asks for collabomanagement pro
e local level of h
ocal level deliverying for region h
should create finaultimately is exp
n primary care nt programs in prmprove quality ofbeen organized
shared databasee enabled to followutcomes with thosspecific cross-semproved healthcaup after hospitaliz
23
result occurs grants ded to s. The hcare es of
ogram ore of n and must
ration ogram
health
y exist health ancial ected
imary f care when
e. An w the se by ctoral
are as zation
24
The arrangemein a later stagediseases 39. Quality improvA non-financiaproviders. The between providdatabase existsQuality Project.can be performinformation abotreatments. Theabove mentione
1.5.6. Outcom
1.5.6.1. StakeThe National BDenmark. Hoprofessionals infunding of hospCCM. This concprimary care, asand quality mofor GPs lays inused to a highe
1.5.6.2. GPs The general pracollaborate andpractice are upprimary healthcthe primary cardo not have theRe-arranging thpatient enters t
ent with the GPs ise this will be exte
vement incentiveal incentive for q
aim is to increaders and to enhans of 32 database. Through these d
med for specific pout necessary heae databases are ed NIP is part of t
mes
eholder collaborBoard of Health
owever, reluctann hospitals as it ipitals will be affectcern is also due fos it is unknown wh
onitoring of the se the need to com
er level of self gov
work independeactitioners work id to participate inp to the GP. As care may be hindere, they will not be dominating comphe continuum of hthis continuum at
s currently only foended towards pa
es through benchquality improvemase the clinical dnce the quality of es nationwide andatabases data apatient groups. Talthcare improvem
the responsibilithis database.
ration has started to
nce occurs soms unclear to themted by the deliveryor GPs working ashat the implicationector are. Howev
mply to the clinicalvernance and prof
ent ndependent whic
n team-work 9. Ala result, implem
ered 39. Even thoube able to coordinpetence. ealthcare could let the wrong time
or diabetes patienatients with other
hmarking of provment is benchma
databases benchcare. This clinicad is part of the
are collected and his provides for ements and total qty of the regions
implement the metimes within
m how their work y of care accordins private entreprens of increased reer, the biggest chl guidelines, as thfessional authority
h can lead to a bl decisions regar
mentation of initiaugh GPs are the cnate the network,
ead to problems wof place and wil
Chronic care
ts, while r chronic
viders rking of
hmarking al quality National analysis example
quality of 52. The
CCM in health
and the ng to the eneurs in egulation hallenge hese are y 37.
barrier to ding the atives in centre of
as they
when the ll not be
fopcbsleu
1AwmhhcItApwpfu
1ShmsteImTinimaac
e
ollowed by a Gproblems in commchallenges as ethbe taken into accseems to be a necevel. Consequentunderlying structur
1.5.6.3. IntegratAt the start of the were taken into amanagement prachealthcare centre horizontal commcollaboration betwt was found that kAs a result of alpositive with the hwere supportive topatients. Cohesionurther strengtheni
1.5.6.4. ImprovinStrandberg-Larsenhealth care delivermajor professionstewardship, finanechnology to incremplementation oThe National Institn 18 health carmplementation of assess the impacal. found some pocentres have suc
GP. The nationamunicating and inf
ics and working pount. As patient cessary proceduretly, the standardizre for the more inf
ted effort for peoproject, previous
account. To enhactices were deve
described belowmunication, whichween the participatknowledge-sharingl used methods healthcare centre owards the rehabn between GPs aing 44.
ng health care dn et al. concludery across sectors nal healthcare ncial incentives, aease cohesion beof activities withitute of Public Heare centres. The f the concept of tht of the rehabilita
ositive effects aftecceeded in imple
l e-health initiatforming each othepractices of GPs mobility has incree to keep a consized structure is eformal and person
ople with chronicsly identified barriance the integratioloped or improve
w. An effort was h resulted in ting organizationsg meetings are imto increase integrehabilitation pro
ilitation programsand the healthcar
delivery ed that the aim t
is not yet achievestakeholders.
and broadening tetween healthcarein health care cealth has conducte
aim was to ashe health care ceation programs prr evaluation. In gementing activities
KCE Report 1
ive may solve er, but this raises and hospitals ne
eased, standardizstent system at aeven important anal communicatio
c diseases – SIKers for integratedon of healthcare,
ed as for the Østmade on verticaimprovements.
s was supported 7.mportant for integrgration, patients ograms. Also, thes and valued it forre organizations n
to dissolve barrieed from the view oSolutions couldthe health inform
e organizations 8. entres ed an evaluation ssess the degrentre and, if feasibrovided 7. Aarestreneral, the healths according to p
192S
some other
eed to zation a local as the n 39.
KS d care , new terbro
al and Also
. ration.
were e GPs r their needs
ers in of the
d be mation
study ee of ble, to rup et h care roject
KCE Reports 19
plans. Collaborgeneral practitivoluntary organlimited. The exconsider to estaneeds and locaEvaluation at ØThe CDSMP transferable to preliminary resprogram is widnational licensphysiotherapy t7.
1.5.6.5. Sharetechn
Bodker et al. seseem to be struwhat is meant wcommon thougthey suggest toperational leveThe Danish hethat allow geneOutside the prFurthermore, thwithin the tool association couhave impact oinvestigated to
92S
ration has taken poners, hospitals,
nizations. Coherexperiences so faablish a healthcar
al conditions 54. Østerbro health chas been evaluathe Danish cultu
sults of the CDSdespread implemse 36. The prelimtraining programs
red data en perfonologies ee various challeuctural problems, with shared, integhts need to be oto divide sharedel 55. ealthcare system eral practitioners toactices this tool
he study of Strandto see cross-sys
uld imply an insun the level of clsee future possib
place with severaother municipal
nce across healthr could be usedre centre in the fu
centre ated to see whral social and heMP were also p
mented in the heaminary findings ss as improvement
ormance measu
nges of IT suppothe lack of involv
grated care in a son what will and nd care into the
uses health infoo coordinate with is not widespreadberg-Larsen et astem use. They cufficient developmlinical integrationle impact 8.
l stakeholders, esinstitutions, patie
hcare providers h by municipalitie
uture to find the be
ether this prograalth related conteositive for Denmalthcare system show an impacts for COPD and d
rement : Informa
ort for shared carevement of GPs aspecific project. Thneed to be shareepidemiological
ormation technolohealthcare profes
ad nor is it inter-sat. tried to select conclude that the
ment of this techn. This should be
Chronic car
specially ents and as been
es which est fit on
am was ext 7. As
mark, the under a t of the diabetes
ation
e. There s well as herefore, ed. Also, and the
ogy tools ssionals. sectoral. features
e lack of ology to
e further
FT(cthp(2cs(sc(4mRTgaw
1R(davSaapsas
e
Findings of the ITThe main conclusi1) most of the da
context-specific anhe subject. Shaprofessional bound2) a small subs
contexts and be sharing; 3) in addition, the
specifically designcontexts and expe4) the dilemma is
must not require toResults from the The KOALA projegeneral interestedand as a quality inwith COPD in a co
1.5.6.6. EngaginResults of usingdiabetes) patients
as seen by the shversus disease anSelf-management activated patient. about self-care inpatient related meseen in interventioabout action planshow effect on clin
T project with imions were:
ata produced and nd often difficult taring these typedaries is not feasi
set of data can of use to others
ere appears to bened to meet the
ert domains; , however, that thoo much extra woKoala project
ect shows prelimid in the project at nstrument. Referraommunity setting s
ng consumers, Eg the Guided-Ses improve their lihared decision mnd the relationship
is part of chroVedsted et al. s general practiceeasures and healons using health cs and medical tr
nical outcomes bu
mplantable cardio
recorded as part to interpret unleses of data acrible; still make sense. These data are
e a need for create coordination n
he production of thork 46.
inary results. Thethe level of data
al and baseline asshould be improve
Engage the patieelf Determinationfe skills. Empoweaking, the settled
ps between patienonic care to enscrutinized system
e 56. They found lth services utilizacare professionalreatment. Patientut on patient-relate
overter-defibrillat
of the care process one is an expeross institutional
e across the diffe good candidate
ting new types ofeeds across diff
hese new types of
e municipalities arecording and sh
ssessments of paed 47.
ent n method show erment was imprd conflicts betweets and professionure an informed
matic literature reveffects on clinicaation. Most effects to provide educ
t-led-education died measures.
25
tor
ess is ert on
and
ferent es for
f data ferent
f data
are in haring atients
that oved,
en life als51.
d and views
al and t was cation d not
26
1.5.6.7. ImpoFindings indicareflection modedecision-makingmaking is theconcerning diffibridge the gap a need for comdisease-life appreflecting on tpatient to reflecapplicable in chan overall pictuand reflection thproblem solving
1.5.6.8. AlignOur search hasintroduction of fapplied nor whi
1.5.7. Summ
• The Danisaims regarand Healtstrengthencollaboratioand the rolpromote on
• To improvefor chronicModel andself-managGPs and m
ortance of personate that the use oel in chronic illnesg and problem so
e focus on patieculties in living wbetween the patie
mprehensive chanproach, using preche difficulties a ct on his decisionhronic illness carure of the choicehat are crucial forg 57.
ning finance & Ins not resulted in ofinancial incentivech impact, if any,
mary
h Ministry of Inferding chronic careth Throughout ing of the rolon and coherencele of patients in tene’s own health we chronic care mac disease pathwad rehabilitation prgement and persomunicipal health ce
n-centered commof the person-centss care can improlving. The key aent perspectives
with the chronic illnent and professionnges with strategcise communicatiopatient encounte
ns. Zoffmann et are in general, proes, barriers, and r determining whe
surance outcomes on this es, it is not clear has resulted from
erior and Health e in multiple documLife. Important le of healthcare regarding chronerms of the streng
within the healthcaanagement use is y programs inspirograms for diagnonal action plansentres;
munication tered communicarove care throughaspect of shared
and sharing dness. Communicanal point of view. ies as using a coon adapted to theers and challengl. expect the mod
oviding professionpitfalls in commu
ether decision-mak
item. Notwithstanhow these incent
m these.
has laid down itments e.g. the Hepolicy issues a
re providers annic care on regiongthening of their
are and social conmade of a generred by the Chronnosed patients, is and important r
Chronic care
tion and h shared decision
decisions ation can There is ombined
e patient, ging the del to be nals with unication king and
nding the tives are
ts policy ealth Act are the
nd their nal level ability to text; ic model nic Care ncluding roles for
•
•
•
•
•
e
A national ssystematic anorganizationsnational level failure;
Also on nationProgram (CDpatient involve
Due to an incompetenciesand with patieof for example
Various incenimprove the qincentives foincentives thro
Preliminary refor integratedmodest impacof competenc
strategy was laund disease relat. Until so far, perfor eight disease
nal level, the StanSMP) has been iement; ncreased attentios of health professents has been exe shared decisionntives have beenquality of chronic or GPs and muough benchmarkiesults have revead care delivery (ct of healthcare ceies among GPs to
unched in 2007 ted documentatiorformance measue including COPD
nford Chronic Disentroduced, to est
on on lifestyle csionals, their inter
xamined and resu making;
n introduced in thcare. Examples
unicipalities, and ng; led solutions to o(e.g. financial inentres on health oo coordinate prima
KCE Report 1
to facilitate a on of services arement takes placD, diabetes, and
ease Self-Manageablish a framewo
changes the roleraction with each lted in the introdu
he system in ordof these are: finaquality improve
vercome main bacentives and HI
outcomes, and theary care networks
192S
more cross ce on heart
ement ork for
e and other
uction
der to ancial ement
arriers T), a e lack s.
KCE Reports 19
1.6. Quebe
Figure 6: FramQuebec Stakeholder C
Shared Data &
Engaging Consumers
The diabetes centre My Tool Box Priisme ROCQ
92S
ec
mework for crea
ollaboration: shaMinistryCommuprovidePatientsSystemPhysiciNurses PharmaMontreaNetworSIPA CURAT
& Performance M
TeleheaMOXXILOYAL
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referral PrimaryorganizCSSS/LRUIS Family groups/
ating a Regiona
ared vision and ly - Reforms unity, care ers and system s
m managers ans
acists al Stroke k
TA
easurement
alth
ving Healthcare Delivery
y healthcare zation Local Network
Medicine / Network clinics
l Healthcare Sy
leadership
Aligning FinaInsuranc
Government-fuDM programs
Chronic car
stem in
ance & ce
nded
O
F
e
Outcomes
Future Actions
TEAM/VES
Montreal Network SIPA CURATATelehealthMOXXI The diabcentre PRIISMEROCQ CSSS TEAM/VES
Further insand efficadelivered hMore focdelivered cIncreased understanof care ga
SPA
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h
betes referral
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sights of value acy of team-healthcare us on team-care
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27
28
1.6.1. Stakeh
1.6.1.1. HealtIntegrated delivhealth servicesmanagement pof patient camanagement icommunicationempowerment. outcomes, are with participatinVarious strateg1970s, with theessential one. Tand integrated integrated delivmost provincesprimary care psuch as chronicIn 1984, servicewhen the Canawith all ‘medicavariation exists 2000 on the Cand age-relatebecoming morepractitioner (GPProduct for headesire for a professionals a
holder Collabora
th Care in Canavery systems haves in most Canadrograms are seen
are and outcoms seen as a ss for populatio
Evidence-basedcombined, meas
ng stakeholders 58
gies were carried e establishment oThese authorities
services. Howevvery systems, sucs. Also a start haspractices and a vc disease managees were fragmentada Health Act eally necessary’ ho
between provincanadian healthca
ed chronic diseae difficult: 25% of P) 60. Also, the coalth care was 10more efficient and other stakehol
ation: shared Vis
da e been part of thedian provinces sin as one solution
mes and for reystem of coordi
ons with a fod practices, ecosured and used 8. out by provincia
of the Regional hprovide geograph
ver, there is a lach as integration o
s been made in pvariety of other inement 59. ed and the cultureequated ‘accessibospital and physicces as it is their oware is changing aases are increasf the habitants inosts of care are ri0% for Canada. Tand effective helders 61.
sion & Leadershi
e planning and dence the 1970s.
n for improving theeducing costs. nated interventiocus on self-caonomic and huin interventions
al governments sealth authorities
hically-based coorck of key compoof physicians and romoting multidis
ntegrated care str
e of acute care reble’ health care cian services. In awn responsibilitys the population
sing. Access to Quebec have no sing. The Gross This results in a ealth system for
Chronic care
ip
elivery of Disease e quality Disease
ons and are and manistic together
ince the as most rdination nents of drugs in ciplinary rategies,
einforced services addition, 59. From is aging care is general
National growing
r health
1ThrebTdcCpfowMAthcpreatincinthHTshremSthb
e
1.6.1.2. QuebecThe Ministry of Hhealth and social egional structure
by starting local coThe local centresdeveloped commucare increased, rCommission of Sposition Quebec ocus on the explowas released in 20Multidisciplinary Also, multidisciplinhe province, to pcare through publpromoting integraesponsible for ca
agencies. A joint pime, the federal network initiativesconsequence, innon care continuity he Reforms whichHealth and sociaThese current refsocial service, heahand to respond mesult, local comm
merged into 95 heServices Sociaux)he possibility to bring all care prov
c Health and social
services. From 1to coordinate an
ommunity centress took care of unity-based actionresulting in ReforStudy for health a
as leader of inteoration of an optim007 58. teams in primar
nary team-based pprovide incentivesic policies 59. Theated care, prov
are coordination bpartnership starte
health Transitios, for elderly, dovations in the sywere stimulated,
h started in 2005.l service centresforms are designalth care integratimore effectively tomunity centres, aealth and social se) 59. These CSSS implement innovaiders in a certain
services has th970 on Quebec
nd integrate healts and the creation
the clinical andn. As of 2000, therms in 2005 amoand Social Servicegrating disease mal use of medic
ry care practices in primas to private groue local services stvide multidiscipl
bridging hospitals ed between 1991 on Fund implemediabetes and caystem and the sh resulting in smo
s ned to reinforce pon and their effici
o the raised demaacute hospitals anervices centres (Cexist as local heaative models of cregion together.
KCE Report 1
e authority over began to implem
th and social servof regional autho
d social servicese budget for integong others 58, 59.ces (CSSS) aimemanagement, w
cines and a drug p
ary care are initiatp practices in prtill play a major roinary care andand community-band 2001. During
ented integrated ancer patients. Aaring of best prac
ooth implementati
primary care, impiency and on the nd of health care.nd long-term hosCentre de Santé ealth networks and care delivery 62.
192S
most ment a
vices, orities. s and grated . The ed to
with a policy
ed by rimary ole in are
based g this care
As a ctices on of
prove other
. As a spitals et des
raise They
KCE Reports 19
University initiIn addition laruniversity-baseof Montreal hasde recherche eintegrated disereforms there isclinics. These foPolicies and frSeveral Acts haachieve integrprograms. Withinitiated, startin2007, Quebec was published agood health hDuring projectprocesses are ttheir surroundindeliver chronic private partnersSome example• The MontreThe Network vcare to efficienand control coCreating strokewith predictors providers fromdisease managIn 2005 variougroup to fill up improve the coworking group Institute of Hea
92S
iatives for chronrge university-affd healthcare netws launched a diseen gestion thérapeease managemens also a place foocus on reinforcinramework for chrave been revised ated care, priorhin the chronic cng with a provinci
framework for pafterwards. The aabits and better t development taken into accounng play a central care multidiscipli
ships are commones eal stroke network
validated models tntly and effectiveosts for populatioe care continuums
of discontinuous different discipement model hass stakeholders wthe gap in inform
ontinuity of care bcould expand af
alth Research and
nic care filiated hospitals works (RUIS). Fu
ease managementeutique), aiming t
nt programs in Qr the family medi
ng access and keeronic care and policies have
ritizing mental hcare program sevial public health p
preventing and mavailable money h
detection or prethe existing he
nt as well as prevrole in all partnernary teams are un in disease mana
k that build upon cly optimize chron
ons with specific s represent highly
care i.e. the involines and organ
s been used as frawere brought togemation, relationshbetween the diffefter substitute fund intentional com
were merged inurthermore, the Ut research group to adopt the adva
Quebec 58. In theicine groups and ep the care contin
e been developedealth and chron
veral projects havprogram plan in 2
managing chronic has been used to evention of diseealthcare structuious results. Patierships and projec
used 61. In Quebecagement.
continuity of servinic disease mananeeds, includingrelevant solutions
olvement of multiizations 62. The amework. ether in a stroke hips and manageerent care providending from the Cmunities of practi
Chronic car
nto four niversity (Groupe ances of
e current network
nuity.
d to help nic care ve been 2001. In disease promote ases 59.
ure and ents and
cts 58. To c public-
ces and agement g stroke. s to deal ple care chronic
working ment, to ers. The
Canadian ice were
fopTsc• SiscaTCspoSas•
TinapbTcpinapQ
e
ormed. This netwprevention to sociaThe communities several outputs hcollaborative platfo System of InteSIPA is a model os community-bascomprehensive, cand rapid responsThe project consCase managers psetting, the patienplay an important of montreal, in paServices Board 58
accountable for sservices provided Curata: integr
anti-inflammaThis integrated apn Quebec. The prability to identify pharmacological abased decision suThe program had care, educational tphysicians and onterventions is algorithm. Severapatients, pharmaQuebec58.
work is still growal participation, taof practice form have been deveorm has been staregrated Services of integrated care sed and patientcontinuous care ase. SIPA was resists of multidiscip
play a crucial rolent, the central rolerole in this projecrtnership with scie8, 63. GPs receiveservice utilization in the communityrated approach totory/ analgesic Meproach has been rogram has as aipatients with os
and non-pharmacpport algorithm. several interventitools for pharmacoutcomes evaluathe developmenl stakeholders pa
acists and Healt
wing. The netwoaking patient grouthe base of learn
eloped and implerted 62. for the Frail Elderfor the elderly wit
t focused. The and mobilizing a ponsible for the dplinary care prov
e in the coordinatie of the GP and tct. The project wasentific teams and ed specific fees.
in terms of hosy 63. o improve the apedications set up for the treams to improve prteoarthritis and tcological therapie
ons relating to thecists and patients, ation tools. Furthnt of the evidearticipate, such asth and Social
rk has switched ups better into accning organizationsemented. Also a
rly (SIPA) th severe disabilitaim was to enneeds-based, fle
delivery of all servvider teams in Cion and follow-upthe information sys implemented in the Health and S
. The SIPA teampital stays as we
ppropriate utilizati
atment of osteoarrimary care physicto choose approes using an evide
e CCM such as ptraining workshop
hermore, one oence-based treats healthcare provServices Ministr
29
from count. s and an e-
ties. It nsure
exible, vices.
CSSS. p. The ystem parts
Social m was ell as
on of
rthritis cians' priate ence-
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30
1.6.2. SharedKnowledge tranchronic care, organizations tchronic care iKnowledge tranare aware of thwith managing Gagnon et al. aabout organizaorganization pinformed knowlExamples of shTelehealth The Ministry ohealthcare netwservices shouldQuebec 65. Onecoordination anthe clinical teleintegration. Thisand accessibletelehealth is a coordinator seintegration withprovision and mandatory65. Medical OfficeMOXXI is an idrug and disearelated illnesseThe project hasHealth Infostruc
d Data & Performnsfer and organizabased on the
to integrate newn practice seemnslation plays hehe existing evidechronic conditionsaimed in their stuational readiness
prior to implemeedge related to th
hared data and pe
of health and soworks (RUIS) to d enhance the ae of the RUIS devnd integration. Thehealth coordinats role is essentiae patient care amajor concern inems to be impohin the network.
utilization, an
e of the twenty-firnteractive systemase managementes and improvems been in variouscture Partnership
mance Measureation readiness toevidence, are n
w research-basedms to be a way
re an important rnce and know hos 64. dy at assessmens that would b
enting evidence-bhe core elements erformance measu
ocial services ask develop the tel
accessibility and veloped a strategihis reorganized ptor to support sel to ensure well-c
as the structures promoting these
ortant for continu. For an effectiv
integrated ca
rst century (MOXm of electronic prt. MOXXI is aimi
ment of managems stages and is fiProgram.
ement o deliver the best necessary 64. Md knowledge on
to overcome throle to ensure thow to use this in
t tools based onbe used to assbased and scienof the CCM. urements are:
ked the universitlehealth servicesdelivery of healthic plan including s
plan included a nervices’ coordinatcoordinated, time-s towards adapte services. Therefuity and sustainave telehealth sere system netw
XXI) rescribing and inng at reduction
ment of chronic dinanced by the C
Chronic care
possible otivating optimal
his gap. at users relation
a theory sess an ntifically-
ty-based s. These hcare in services’ ew role, tion and efficient, tation of fore, this ability in ervice in work is
tegrated of drug-iseases.
Canadian
ItmpeoodimLLthareprefuU
1
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e
t focuses on the management andprescriptions andenhancement of thon compliance of of evidence-baseddecision-support smplemented the pLoyal Lowering blood pherapy through taims to improve theduce therapeut
pressure monitorseminder, feedbacunded by the indUniversity of Mont
1.6.3. Engaging
1.6.3.1. The dian Quebec, the dCDMP running inVerdun since 20exchange on lifeprimary multidiscipnformation is dissand administrativecontinuous quality
application of infd consists of vard reminders for he patient’s role tmedication uptak
d asthma and diasystem. McGill Unproject together w
pressure by impthe assistance ohe health and weic non-compliancs, integrated teleck and education dustry and condtreal Hospitals 58.
g Consumers : s
betes referral ceiabetes referral c
n the health and007. It consists style modificationplinary communityseminated to all se outcomes after sy improvement 66.
formation technorious component
physicians and through self-manake. Another compabetes guideline niversity research
with several stakeh
proving complianof technology-enhell-being of hypertce. Patients are ephone support s
material. It has bucted by the Re
some illustrations
entre centre is an examd social services
of individual an and other they teams and sec
stakeholders, inclusix and 12-months
KCE Report 1
logy to drug ands, such as elec
on the other agement and feedponent is the utilizthrough the adva
hers have initiatedholders 58.
nce with hypertehanced tools (LOtensive individuals
provided with system for autombeen started in 2esearch Centre o
s
mple of contempcentre du Sud-
nd group knowerapies and is licondary care. Prouding results of cls, initiating a cultu
192S
care tronic hand
dback zation anced d and
ension OYAL) s and blood
mated 2002 , of the
porary ouest ledge nking
ogram linical ure of
KCE Reports 19
1.6.3.2. My TThis a standaprogram develofamilies to be involvement anbeing used thcommunicationis that providinenables better therapeutic ben
1.6.3.3. Progrmédi
The comprehesuivi médical echronic diseasemanagement eNolte, 2008 ThGovernance isrepresentativesclinics, individua
1.6.3.4. RecoQueb
The project “Re(ROCQ) aims twomen aged 5further osteopoThe assumptiothe target group
92S
Tool Box ardized and prooped at Standfordmore active part
nd empowermentroughout Canad as being highly ing patients with
patient understanefits 67.
rammes régionaical et d'enseignnsive « Programmet d'enseignemenes asthma, COPD.g. self- managem
he program was ls by a steering s, health institutioal providers and i
ognizing Osteopobec (ROCQ) ecognizing Osteoto improve the di
50 years and oldeorosis-based compn is that ROCQ p 58.
oven effective p University. The aticipants in their t seem to be ima. Patients and mportant. The asaccess to their
anding of diseas
aux intégrés d'inement (Priisme)mes régionaux innt » aim to improD and diabetes. ment, based on thaunched in 1999committee of r
ons, community ndustry 58.
orosis and its Co
porosis and its Ciagnosis and trea
er with fragility fraplications. The prwill result in imp
patient self-manaaim is to help patieown health. Satis
mproved. The procare providers
ssumption of My Town health info
se risk and conc
formation, de su) ntégrés d'informaove the manageThe focus is on
he primary care s9, funded by the iregional health agroups, private
onsequences in
onsequences in Qatment of osteopoactures and a higrogram started in proved knowledge
Chronic car
agement ents and sfaction,
ogram is indicate
Tool Box ormation comitant
uivi
ation, de ement of
disease tructure. industry. authority medical
Quebec” orosis in h risk of 2003 58.
e among
1Mdpbnow
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1.6.4. ImprovingMontague et al. fodisease managemphysician professbarriers for activnetworks (IHSNs) of these networkswere enrolled in S
1.6.4.1. PrimaryThese organizatioaffiliation, utilizatioutcomes of carene leaders is to ntegrated care inprotocols for specwith support netwhealth records amotivation and sel
1.6.4.2. Health aThe Health and planning and coonetworks and fopartners. The CSSesidential and lon
a given territory. Pof the networkssupporting and coand service perforare now a large au8. CSSS in Que
package of servicmodels aiming fmanagement; 3) t4) to develop integ
g Healthcare Deound that physiciment in particulasionals. Stampa ve participation o
as they play a crs 63. The target gIPA, one of the m
y healthcare orgaons vary in theiion of services, 68. In the provinccreate multidiscip
nitiatives, for exacific patient popuworks and informand patient edulf-efficacy 61.
and social servicsocial services
ordinating all hear collaborating wSS are a collaborang-term care centPartnerships are b
7. The regional oordinating their rmance in their teutonomy in planniebec have four ces to certain tafor comprehensivto create a circumgrated structures m
elivery ans are not alwa
ar for team careet al. looked intof GPs in integrucial role in the sgroup they used cmentioned example
anization ir performance w
experience of ce of Quebec a splinary family medmple electronic pulations and pati
mation systems tucation centres
ces centres – Locentres (CSSS)
alth and social swith their healthation of local comtres and the comm
built, which are essauthorities are mlocal networks anerritory, which is ving an organizing objectives: 1) to
arget groups; 2)ve, ongoing an
mstance encouragmatching with the
ays supportive towe involving also to the incentivesrated health sersuccess in the deconsisted of GPses before.
with respect to care and perc
hared opinion of dicine care teamsprescription progient self-managemthat include elec
to stimulate p
ocal Networks ) are responsiblservices in their h and social nemmunity health cemunity hospitals wsential to the opermainly responsiblnd monitoring nevery beneficial asservices and act
o provide a comto make use of d personalized
ging continuity of e environment 7.
31
wards non-
s and rvices
elivery s who
client ceived front-s and rams; ment, tronic atient
e for local
twork ntres, within ration le for
etwork s they ivities
mplete care case care;
32
The main challebetween these regarding accoelectronic clinic
1.6.4.3. UniveEach RUIS ceresearch, and health authoritie
1.6.4.4. FamFamily medicinand to make chronic diseaseteam and to inca centre and ofextended openEspecially regatogether. The Fhealthcare clinwork together wthese CSSS 68
Health Teams.Active participmultidisciplinaryimportant to suthe role of nursthe clinics 59.
1.6.4.5. NetwThe Network cThese network on the more vsupport 68. Netwrole. The netwservices and wi
enge for the yeardifferent compon
ountability, implemcal records 59.
ersity-based heantre offers ultra-sprovides coverag
es 59. One of their
mily Medicine Groe groups (FMGs)it more continuo
es. The focus of thcrease the effectivffer extended servning hours andarding the care foFMG policy focusics and the provwith the Local Ce8. FMGs in Que ation of GPs iy teams 63 but thepport physicians ase practitioners is
work clinics (or aslinics are funded clinics are compleulnerable patientswork clinics are la
works have collabith laboratories fo
rs to come will benents 7. Also anmentation of bes
althcare networkspecialized care, ge for part of thr tasks is to develo
oups ) aim to increase ous, especially thhese FMGs is to wveness of healthcvices. Other examd appointments or chronic patientses on the agreevincial governmenentres and intendbec are very sim
s important for e role of nurses bat different levels s encouraged, bu
ssociated medicby the Montreal ementary to the Fs as well as on arger than FMGsborations for the r technical suppor
e to increase cooreffort needs to b
st practices and
ks (RUIS) coordinates traine province’s 18 op telehealth serv
the access to hehe care of patiework as a multidisare 59. GPs collab
mples are that FMGare not manda
ts, nurses and Gment between th
nt. The FMG thed to be complememilar to Ontario’s
the success obecomes more anof the care proce
ut not yet fully en
cal centres) Regional Health
FMGs. These cliniproviding basic tand nurses play delivery of psyc
rt 59.
Chronic care
rdination be made creating
ning and regional
vices 65.
ealthcare nts with ciplinary borate in Gs have
atory 59. Ps work
he public mselves
entary to s Family
of these nd more
ess. Also nrolled in
Agency. cs focus technical a larger
chosocial
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1.6.4.6. Toward (VESPA
The VESPA progrAsthmatiques”), aiof patients and toasthma. The progNetwork, Merck nvolved, such as tassociations and t
1.6.5. Aligning F
1.6.5.1. Financinn comparison wmanagement orgacademic, governprograms in collabn disease manageesearch-based ph
1.6.5.2. AdditionThese incentives FMGs were initiaAdditional fundingenable the start-upan electronic dataPartnership Progra
d Excellence in AA) ramme (“Vers l'Exims to optimize aso alleviate the soramme is an initiaCanada and Asthe patients, regiothe provincial asth
Finance & Insura
ng of initiativeswith the USA, Cganizations, alth
nment and/or comboration. Furthermement has recentharmaceutical com
nal incentives foare available sin
ated in 2005 fung comes from thep of network clinicabase is funded am.
Asthma Managem
xcellence dans lessthma care, to imocio-economic buative of the Quebstra-Zeneca. Seveonal health authorhma education net
rance
Canada has no hough the phammunity partners more, a Canadiantly been created bmpanies 58.
r multidisciplinarnce 2000. As a ded by the Cane Montreal Regiocs in the region 68.
by the Canadia
KCE Report 1
ment programm
s Soins aux Persoprove the quality urden associatedec Asthma and Ceral stakeholdersrities, patient advotwork 58.
commercial disarmaceutical ind
have initiated sen Council for Reseby a group of Can
ry team practiceresult, the CSSS
nadian governmeonal Health Agen. A program to den Health Infostru
192S
me
onnes of life
d with COPD s are ocacy
sease ustry,
everal earch
nada's
es S and nt 59.
ncy to velop
ucture
KCE Reports 19
1.6.6. Outcom
1.6.6.1. StakeSuccesses andAt the Canadiahave been repomutual goal, pshared informaOn the other hstakeholders, ssystems, and inis in accordancstudied the pubviews of the bThey found thatowards the imtowards initiativincluded coordicare; increasemeasurements team care, incpatient care, thincreased patiehealth records Notwithstandingmanagement beBarriers: indepThe Quebec restage. GPs oftcontinuity of heturnover of staregional health regarding the achieved a cultteams. Reasoncultures within
92S
mes
eholder collabord challenges
an level several suorted so far, suchrofessional care,
ation on practiceshand, challenges shown effects forncreased educatioce with a study oblic's perception oburden and effectat more than halplementation of dves to improve inated interventio
ed wellness proand feedback to
cluding the use ohe public and doent involvement in
to facilitate comg not all stakehoecomes more compendency, lack oeforms and cliniten work indepenealthcare remain
aff in reaction onauthorities play amerge of organ
ture change yet rens for this are a lorganizations 59.
ration
uccesses of chroh as community b
patient self-mans and outcomes;
remain at the ler effective team on for both patienof Montague et alof their health stative managementlf of all stakeholddisease managemthe healthcare ons to improve homotion; and inc
o all stakeholdersof non-physician octors were less decision-making munication are inolders being posmmon. of support ical integration andently. Improved a point of atten
n the reforms is a role here, becaunizations. Consecegarding collaboraack of interest ofFurthermore, it is
nic disease manabased partnershipagement; measuand visible leadevel of engagemecare; usable info
nts and caregiversl. (2009) in Quebatus and all staket of chronic diseders had a positiment programs asof chronic patienome, community acreased use of s. Regarding the
professionals to supportive stakeand the use of e
n room for imprositive, integrated
re still in implemd access and enntion. Also the inacting as a barrse of their lack of
cutive reforms hation and multidisf physicians and s unknown if the
Chronic car
agement ps with a ured and ership 66. ent of all ormation s 66. This bec, who eholders' eases 63. ive view s well as nts. This and self-
clinical value of provide
eholders; lectronic
ovement. disease
mentation nhanced ncreased rier. The f support ave not ciplinary different regional
hinthS•Ocd1ppthimotoelaop•Shaaapimsinssppna
e
health authoritiesntegration 59. Thihe process of chaSpecific example Montreal Serv
One of the Moncollaboration of stdevelopment of a
20 nurses. Shapractice and was aproblem-solving, che increased shmplement best-prof cost and enhano increase collabengagement to beatter, an enhanceorganizations neeplatforms62. System of Inte
So far SIPA has home healthcare and improved intealso found in acceand a reduction ofpositive effect wasmprovements regservices networksntegrated networksame as actual psetting is complparticipation in thepatients in the intnetwork and their about SIPA. Chall
s are achievings is common in
ange 66. es vice Network ntreal service netroke care deliverbilingual training ring of 'know-hoappreciated by pacapacity and trustharing of ‘know-ractices. At organnced service delivboration of stakeecome the best
ed understanding oed to occur as
egrated Services resulted in a decand access to ho
egration and contiessibility of commf 50% was seen ins found for providgarding the partic within SIPA 63. Gks. Furthermore, iparticipation. Thelex and depende study is mostlytegrated setting, attitude towards
enges were the h
g effective servidisease managem
etworks was very. Another netwo
session and wasow' had a positivarticipants. It show. Also participantshow’ and the u
nizational level moery were seen 62.eholders in Quebpractice for strokof successful dev
well as the u
for the Frail Eldercrease in hospitaome care, no incnuity of care 58, 69
munity-based hean acute hospitalizder satisfaction 69
cipation of GPs GPs play a crucialintention of GPs t participation of
ding on severaly depending on crelation with the SIPA. However,
high expectations
ice coordination ment programs d
ery successful inork had success is offered to moreve impact on clwed positive resus were most positunderstanding hoore efficiency, sa Nowadays the g
bec and enhanceke care. To reacvelopment of integuse of e-collabo
rly (SIPA) l wait times, impr
crease in overall 9. A positive effeclth and social ser
zation of elderly. A9. Stampa et al. fand integrated hl role in the succeto participate is noGPs in an integ factors. Active
collaborative praccase manager iall GPs were poof GPs as well as
33
and during
n the in the
e than linical lts on tive of ow to avings oal is e the h the
grated rative
roved costs
ct was rvices Also a found health ess of ot the
grated e GP ctices, n the
ositive s lack
34
of information physicians 63. • Curata Evaluation has and use of evid
1.6.6.2. ShareGagnon et al. aassess organizin line with thebetter implemeimprovement 64
Telehealth Telehealth is uimprove accesdevelopment oundertaken by strategic. HereFurthermore, thprogram with cimplementationMedical OfficeThis interactivedisease managcare, good inpharmacists. Fof the programmistakes usingadherence will (Health Canadaidea is that thediseases 58.
1.6.6.3. EngaThe Diabetes R
about the prog
shown an improence-based outco
red data & Perforaim to develop a zational readinesse Canadian healtent evidence-ba
4.
used as a tool toss and continuityof a new profess
persons who mee an opportunithe results show clear descriptions 65.
e of the twenty-fire system of electrgement show poteraction with puture research w
m. The hypothesig electronic presc
occur. These area, Health and thee impact of this p
aging consumersReferral centre
gram and difficu
ovement in physicomes 58, 70.
rmance measurframework which
s for knowledge trthcare and possi
ased outcome re
o meet up with thy of services. Tsional role. Thiseet the competenty is seen for
that a clearer s of the roles sh
rst century (MOXronic prescribing
ositive results; higpatients and goowill be performed
is is that a posicribing and improe likely to produce Information Highrogram can be ex
s
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rement could be used aransfer. The tool ible services planelated to chron
he increased presTelehealth suppo
s complex role mncies, clinical as
nursing adminiconcept of a Teould be made be
XXI) and integrated d
gh satisfaction ofod relationship won the cost-effective result in meovements in pree a cost-effectivehway Division 200xpanded to other
Chronic care
between
owledge
as tool to must be nning to
nic care
ssure to orts the must be
well as istrators. elehealth efore its
drug and f quality with the ctiveness edication scription
e system 04). The r chronic
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nitial results havhabits, clinical conhowever, remains more facile datamprovements areand robust measntervenes with thsecondary intervenAdditionally, Ahmactive case findingmanage the wholedata collection’, tesecurity via commchange managemProgrammes régd'enseignement (Results have bprofessionals. Alson asthma-related
1.6.6.4. ImprovinDue to public-privon practices andmanagement wasevidence on thpartnerships are ecare system. Gopossibility to use thThere is also incmprove clinical anprevention 66. Thecommunity-based communication syHealth and socia
ve demonstratedntrol indicators and
the lack of a systa collection ande not always able surement and coe promise that prntions 66. ed et al. pointedg in the general poe patient populatioechnology in an munication, standent which has als
gionaux intégrés(Priisme) een found for o a decrease of 3illnesses 58.
ng health care dvate partnerships d satisfaction ams still very newat moment suefficient in knowlgovor et al. sughis knowledge ancreasing evidencnd fiscal outcomee proposed redespartnerships with
ystems – all key inl services centre
significant imprd patient satisfacttem-wide informat
dissemination.to make, because
ommunication syrimary care reduc
d out that CDMPopulation is part oon. Best model coelectronic health
dardization whichso barriers. s d'information,
education of 30% in use of the
delivery positive process
mong stakeholdew in Quebec an
ggested that dedge creation an
ggested that futud go from there 58
ce that teams, ines in chronic disesign is often focuh patient self-manngredients of effeces
KCE Report 1
rovements in lifetion. A great challetion system to facAhmed, 2010 Q
e of the lack of fleystems, which inces mortality and
P can only work of an overall strateonsists of ‘rationa records, sharing
h is still question
de suivi médic
patients and hhospital could be
changes can be ers. In 2008 disnd Canada. Avadisease managend its transfer inture projects have8. ncluding patientsease managemenused on shared gnagement and effective CDMP.
192S
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KCE Reports 19
Delegating taskas this has beedevelop and imother health proof the volunteethe supportpharmaceuticalorganizations, management aToward ExcellA lot has beeknowledge andextended. Theintegrated clinic
1.6.7. SummNotwithstandingsince the 1970primary care fragmentation a• Quebec h
coordinateas multidisprimary car
• Further orgcentres, acand social also includ
• Performancbase and a
• Initiatives multidiscipaccessibleinitiatives f
92S
k towards nurses en the tradition thmplement new rooviders other than
ers from clinic praof the primary health care induhas been assocnd outcomes of Cence in Asthma
en learned from d care of disea
e university-basedcal group practice
mary g the existence o0s, disease manpractices were
and to increase thhas been implem, improve and int
sciplinary team-bare; ganizational expacute hospitals anservices centres e family medicinece measurement are sometimes paare launched tolinary teams or n, comprehensive, inancial incentives
is one of the conhat GPs/family doles and competen physicians 7. Thactices, academiay care professistry, government
ciated with markeCanadians with hy
Management (TEthe results of T
se in Quebec. d networks conts 58, 60.
of integrated delinagement prograintroduced in Qe accessibility of
menting regionaltegrate health anased practices in
ansion took placend long-term hosp
or local health ne groups;
and data collectiort of telehealth ex
o redesign primanetwork organizaongoing and per
s were created;
ncerns among phyoctors. It is challeencies for nurses he collaborative aa, and governmenional associations, charities, and sed improvements
ypertension 71. EAM) (Vespa) TEAM so far abThe program hatinue education
very systems in ms and multidis
Québec to diminchronic care; community cend social servicesprimary care to r
e when local compitals merged intoetworks which no
on takes place onxperiments; ary care and totions in order to sonalized care. F
Chronic car
ysicians, nging to and for
approach nts, with ns, the scientific s in the
bout the as been and the
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nish the
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o create provide
For these
•
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e
Preliminary rQuebec reformphase’ given integration stimprovement for elderly, imand healthcarnurses and no
Challenges repatient populaand data colle
esults show resms are characterthat structural inttill being in its regarding access
mproved knowledgre providers, increo increase in costsemain regarding aation, organizatioection.
ults and room fized as ‘being stiegration is mostlyinfancy. Simultansibility, reduction ge of physicians, eased use of teles;
an overall strategynal readiness reg
for improvement.ll in its implemeny achieved and clneously, results in hospitalization
satisfaction of paehealth, involveme
y to manage the wgarding actual cha
35
The tation linical show
n rate tients ent of
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36
1.7. PennsGiven the limitpresentations), Notwithstandingregarding the in
Figure 7 – FraPennsylvaniaStakeholder C
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KCE Reports 19
1.7.1. Stakeh
1.7.1.1. ChroIn 2007 the Coeffectively implprescription fointegrated stratbetter manageinfections, enacaffordable healaccess to healtthe CCM and ththe PennsylvanChronic Care Reforms), in cphysician profeInitiative are imincluding insureinstitutions andstrategic objeccould be summand improve ouIn January 200insurers and pCentered Medicits multiple regyears. The prodelivery with a target disease. were describedof whom the maThis initiative uMedical Home a validation tomanaged. Impservices during
92S
holder Collabora
nic Care Initiativost Containment Cement chronic dir the healthcaretegies to eliminate chronic conditct common sensth care insurancethcare for every Phe patient-centerenia Department oCommission, ancollaboration with
essional organizatmplemented. Thisers, healthcare o government age
ctives according marized as a focuutcomes for patien08 the Governor’providers to estacal home (PCMH
gional collaborativgram can be seeresult to improve In 2007 the char and distributed toajority provide primuses the Physiciaof the National Cool to see if the
proving Performang the preparation
ation: Shared Vis
ve Commission devesease managemee system of Pete inefficiencies intions, eliminate
se insurance refoe for the uninsurPennsylvanian. Ted medical home of Health (Governd the Governor’sh healthcare protions, regional rols is done by a porganizations, heancies. The Chronto the Chronic C
us on achieving ants 72. ’s office of healt
ablish incentives ). More than 150
ve are enrolled, wen as an examplethe health of pati
racteristics of a pro four physician mmary care in the Uan Practice Connommittee of Qualnewly delivered nce in Practice phase and helps
sion & Leadersh
eloped a strategicent in Pennsylva
ennsylvania is an the healthcare health facility a
orms and offer acred, with the aim his is done by comodel. On the initnor of Pennsylvas Office of Healofessionals, payelouts of the Chronpublic-private paralth systems, edunic Care Initiative Care commissiona change in infras
th care reform cofor CCM-driven primary care pra
who committed fe to change primaents. Diabetes is ractice-based car
membership organUSA. 73. nections Patient-City Assurance (NCcare is more ef(IPIP) provided the practices to
Chronic car
hip
c plan to nia. The set of system,
acquired ccess to
to offer ombining tiative of
ania, the lth Care ers and nic Care rtnership ucational has four
n, which structure
onvened Patient-ctices in for three ary care used as
re model nizations
Centered CQA) as ffectively support
succeed
ththlapmreinC(PPcintibfoocinmORMA•
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P
e
he implementatiohe quality of heaawmakers and eprovides informatmedicare advantaeforms such as Pn Pennsylvania 74
Collaboration exisPAHA) and the
Professional cerPennsylvania’s hochronic care initiandustry. It containimeliness, effectivbe skilled, which lormulate a best outcomes. Furthechronic care whichn evidence-basedmanagement of thOther stakeholderReform are PennMinistry of health,Authority. The pres new laws to
patients from changes in
professionals training;
developing a s payment refor
so called nevePatient-Centered
n of the initiative.lth care: it worksexecutive agencytion at governmeage plans, healthPCMH. NCQA rev. sts between the Health Sciencertification and ome healthcare aative as it build
ns a new learned veness, efficiencylead to the patien
practice intervenrmore, homecareh makes them in d patient care, thhe patient. 75. s to meet the aimnsylvania Health , Public Welfare, scription for Pennprovide transpar
health facility-acqscope of practo practice to t
statewide health irm, including the er events. Medical Home
. The NCQA has s in collaboration y personnel. Thent level and nh information tecviews are mandat
Pennsylvania Hes Institute to da staff accred
agencies. This ces on the strengmodel, the STEE
y, equitability, patnt’s multidisciplinantion plan to ac
e providers have the best position
hrough manageme
of the Governor’sCare Cost Conand Insurance a
nsylvania also inclrency in health qquired infections;ctice laws to athe full extent o
nformation exchaMedicaid program
as mission to impwith federal and e public policy ational work incchnology and detory for all health
Homecare Assocdeliver Chronic ditation programrtification support
gths of the homeEEP framework (stient centerednesary case conferenchieve positive pa front-line positi
n to support physient and enhance
s Office of Health tainment Counci
and the Patient Sudes 73: quality and to pr
allow several hf their education
ange; m no longer payin
37
prove state team
cludes elivers plans
ciation Care
m to ts the ecare afety,
ss), to nce to atient ion in icians
e self-
Care l, the
Safety
rotect
health n and
ng for
38
Health care setprimary care. TPCMH is coordteam of healthinvolved. The technology is ucontinuously imSouth East Pemodel SEPA consists practices focusextent this inteprimary care phome 76. The pthe monthly reppractice coachpractice connecpayer financial private insurers
1.7.2. Shared
1.7.2.1. The rInnovative techchronic diseasecarefully. It hasprovided health• The implem
effects. Theregistries ftracking an
• The DeparimplementaEspecially
ttings which impleThe health care sdinated and integr professionals an
provided care used and there is
mprove the quality ennsylvania (SEP
of the five-countsing on diabetes.ervention had an practices applyingprogram consisteporting of quality hes, national comctions patient-cenreimbursement.
s. IPIP measures w
d Data & Perform
role of technologhnology can be e management as low costs and ish care for health pmentation of techne CCM relies on tfor both public
nd the provision ofrtment of Veteraation of IT and reeffective here is t
ement the PCMHsystem as such israted into this. Thend the patient (a
is evidence-bas an ongoing meof care 76.
PA) implementat
ty metropolitan Ph Gabbay et al. (effect on the str
g CCM driven Pd of five parts, thindicators, improvmmittee for quantered medical ho
Funding came frwere used to rece
mance Measure
gy seen as an eas
as long as it is ss flexible. It can hrofessionals and nology in diabetesthe use of technoand private heaf quality longitudinn Affairs is a goegistries on a larhe electronic med
s provide compres used as base, e physician is leand his family) is sed, health info
easurement to be
tion of the chron
hiladelphia region2011) evaluated ructural transformPatient-Centeredhe learning collabving performance lity assurance pme recognition anrom six organizateive common repo
ement
y supplement toshaped and implehave a positive impatients 77. s care has shownlogy with disease
alth systems to nal care. ood example of rge-scale in chrondical registry syste
Chronic care
ehensive and the
ading the actively
ormation e able to
nic care
n and 25 to what
mation of Medical
borative, through
physician nd multi-tions, all orting.
current emented
mpact on
positive -specific facilitate
effective nic care. em.
•
•
•
•
1APPrePcP
e
Introducing teunderstandinga (better) linkpatient outcom
Next to a betwebsites and
Also, the actimanagement technology hpractices andmotivational mobile phonethus dealing w
On the leveltechnology havia emerging alerts and reregistries thatPersonal heahealth profescare.
1.7.2.2. PracticeA partnership is Physicians with thPractice (IPIP) toegistry to the pra
Practice Transforcoaches and patiePerformance in Pr
echnology in chrog of how to use finage between impmes. tter electronic regtelemedicine canve participation o
can have a pas the possibility
d routines related level. Furthermo
es) can have an iwith chronic care. of decision sup
as the possibility ttechnologies that
eminders, interact comprehended dlth records can im
ssionals and patie
e Transformationstarted between he Pennsylvania
o provide Practicctices to completmation Support
ent registry to the ractice (IPIP) 79.
onic care is also nancial incentives
proved practice, p
gistration system, improve chronic of patients througpositive impact y to empower pto their illness o
ore, microprocesnstant impact on
pport and clinicato impact on chrot adds intelligencective workflow andata, such as heamprove the comment as it enable
n Support (includthe Pennsylvaniachapter of Impr
ce Coaches and e the disease mahas the objectivpractices. It is pa
KCE Report 1
promising for a bs, given that it proprovider processes
, static and interacare.
gh technology viaon chronic car
patients to learn on an educationassor technology
self-managemen
al system informnic care. For exa
e via guideline-dirnd care coordin
alth data and cost munication betwees better synchro
ding technology)a Academy of Froving Performan
a web-based panagement prograve to provide praartnered with Impr
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better ovides s and
active
a self-re as
new al and
(e.g. nt and
ation, mple, ected ation, data.
en all onized
y) Family
ce in atient
am 78. actice roving
KCE Reports 19
1.7.2.3. ImproThe IPIP progrand provide a first instance, thChronic Care interventional www.pafp.com improvements Care Coalition College of Phyjointly applied fDepartment of H
1.7.3. EngagThe diabetes edthree componeevidence-basedmonitoring, andeducation by cuvisit diabetes c“promoters” to e
1.7.3.1. ExamDYNAMIC: diaThe program ainertia throughbetter diabetes evaluated incluwith the aim to
1.7.4. ImprovPatient-Centerecare organizatiimprove commmake healthcar
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oving Performanam was designedbetter infrastructuhis program provInitiative and dcoaching sertogether with
in collaborative (Academy of F
ysicians,Chapter for the IPIP progHealth and most o
ging Consumers ducation and trea
ents of the progrd approach thad evaluation of culturally competencounseling prograenhance self-man
mple betes programmaims to improve provider use of soutcomes 80. A mding nurse case mmake a behavior
ving Healthcare ed Medical Homeions. The aim isunication betweere more continuou
nce in Practice (d to bring togetheure for primary cavides support servdata managemenrvices for loweducation for hdata sharing. Th
Family Physiciansof the American
gram 72. It is fundof the insurers.
atment initiative wram are implemeat allows for tclient services; thnt health educatoram that provides nagement strategi
me patients' self car
standardized clinimodel of diabetes management andchange happen.
Delivery , based on CCM,
s to enhance accn patient and he
us 1. The NCQA ra
(IPIP) er stakeholders ware within the stavices to the Pennnt for all practicw-performing pealth professiona
he Pennsylvania s, Chapter of A
Academy of Peded by the Penn
as launched in 20entation of the Cthe electronic the provision of irs; and the use ofpeer health educes.
re and to reducecal guidelines to type 2 managem motivational inte
is implemented icess to primary alth professionalsated the Patient-C
Chronic car
within PA ate 72. In nsylvania ces and practices als and Primary
American ediatrics) nsylvania
005. The CCM, an tracking, ntensive f a home cation or
e clinical achieve
ment was rviewing
in health care, to s and to Centered
MqSoSmcpsethto
1MPdbofoecfoinTMethasmthq
e
Medical Homes oquality improvemeSochalski et al. ston hospital readmSeveral practices multidisciplinary communication 81
professionals via specifically on seducational activithis study was to ools to patient car
1.7.4.1. ExamplMultifaceted diabPiatt et al. (2010diabetes care inbetween 1999 andof the CCM 83. Pollow up. Theeducation. In addcommunity. The hollow up of their pn the practice for The education curMichigan Diabeteempowerment 83. The facilitation of kand life experienstandards. The amaking, self-care he health care tequality of life 84.
of Pennsylvania ent 1. tudied the effect
mission and readmhave been taketeams wherea
1. Zinszer et al. ongoing educa
kin and wound y to enhance the apply information
re scenarios 82.
le betes care interve0) looked at thr an underserved 2005. One of thatients follow theCCM interventioition, other eleme
health professionapatients. Also a spatients and carerriculum for the pes self-managemThis program aim
knowledge, skill, aces of the patieims of the progrbehaviors, probleam and to improv
as being an ap
of chronic care mmission days comen into account. as others focu
studied the coation, about info
care for diabetcompetencies. O
n on the CCM to
ention ree different inte
ed suburb in Pihese interventionse intervention for on focused on ents of the CCMals were encouraspecial diabetes e providers, for six
patients was basement education cms to increase diaband ability. It combent and is guideram are to suppoem-solving and acve clinical outcom
ppropriate strateg
management progpared with usual Some of these
used on in-pempetencies of hrmation of the tes and provide
One of the objectivo assess and eva
erventions to impttsburg, Pennsyl
s is the implemen1 year, with a 3patient and pro were provided i
aged to restructureducator was avax months. ed on the Universcurriculum, aiminbetes self-care thrbines the needs, ged by evidence-bort informed decctive collaboration
mes, health status
39
gy for
grams care. used
erson health CCM d an
ves of aluate
prove vania tation
3-year ovider n the
re the ailable
sity of ng at rough goals, based cision-n with s, and
40
1.7.5. AligninThe Pennsylvathrough the staCentre for Medcare practice dPCMH for 1 mil
1.7.5.1. ExamPayment modePayments are Patient CentreAssurance. TheTeam-based trScanlon et al. dreduce medicaldiabetes. This were taken intomanagement patients who rqualified commFinancial outcointervention viaCost-effectivenKuo et al. stuDiabetes Outremodel was devcomparison wittaking into accdiscounting cooutcomes wereprogression dat
ng Finance & Insanian Governor’s ate budget procesdicare and Medicademonstration walion Medicare ben
mples el made for infrastrMedical Home
ese payments varreatment for Meddetermined whethl payments and imapproach was b
o account, such askills, and multreceived team-ba
munity health centromes were comp Medicaid paymeness of CCM in audied the cost-efeach Clinic on a mveloped to estimath usual care. Thcount health carests and benefits e obtained from ta, and utilities ca
surance Office of Health s. In 2010 afforda
aid innovation. In as advanced, anneficiaries.
ructure costs andlevels of Nationa
ry by region. 79. dicaid enrolleesher multidisciplinarmprove quality fo
based on the CCas patient registrytidisciplinary tea
ased care at there were compared
pared 1 year befonts 85. a military settingffectiveness of imilitary medical cate the cost-effechis was done ove system, societ
at 3% annuallymilitary data, whme from publishe
Care Reforms isable Care Act estNovember 2010,
n incentive to im
are based on thal Committee for
ry team-based caor Medicaid enrolleCM. Aspects of thy, patient educati
ams. Medicaid de multisite rural fd with those who ore and 1 year a
g mplementing CCentre. A Markov ctiveness of this ver a 20 year timtal perspectives sy. Intervention cohile other costs, ed literature 86.
Chronic care
s funded ablished primary
mplement
he PPC-r Quality
are could ees with he CCM on, self-diabetes federally did not.
after the
CM in a decision clinic in
me-span, such as
osts and disease
1TpwmimTahpfo
1CTdpimppimimimtesdPTins
e
1.7.6. OutcomeThe first results programs are poswithin the patienmanagement, onmprovements in cThe results, seen and on cost savinhighest-risk indivparameters: glyceor overall healthca
1.7.6.1. StakehoChronic Care InitThe Chronic Care delivery by practipatients. Also, themproving the propatients. The focuprimary care. Lesmportance of namportance of a mportance of keeeam meetings aspreading to mordiabetes and asthmPatient-CenteredThis program incon the U.S. It is tastakeholders, such
es of multi-payer P
sitive, for examplnt self-managem implementing
communication anin diabetes care,
ngs. A significant viduals for the mic control, bloodare costs were pr
olders tiative Initiative has shoces which resulte initiators of theogram to manag
us is especially onssons for practicearrative reports a
plan and the aeping track of daand reporting. Thre practices andma and also focus Medical Home
orporates the CCMaken up with enthh as payers, healt
Patient-Centered le on changes in
ment support, oelectronic regist
nd access. , are positive, botreduction could three most crit
d pressure, and comising for the hi
own improvementst in the improveme program are cge the best caren collaboration anes are the importas guidance for ability to learn ata in ways to imhe future of the include more cs on prevention 72
M and is implemenhusiasm and supth professionals a
KCE Report 1
Medical home Pn the patient’s attn change and ry functions and
th on health outcbe seen among tical diabetes clcholesterol. Reducghest risk-group 7
s in primary healtment of the heacurrently updatinge for chronic disnd the infrastructutance of pre-workpractice coachesduring this time
mprove, importaninitiative will in
chronic diseases 2.
nted in various report by many inv
and policy makers
192S
PCMH titude care
d on
omes these linical ctions 76.
hcare lth of
g and sease ure of k, the s, the e, the ce of clude than
gions volved .
KCE Reports 19
South East Pemodel Team-based cahave been reimimpact on diabinvolved partiesinitiative was dissemination aShared data &The role of tecTechnology is aSiminerio et ainteroperable frlevels, such asstructure and gestablish policyand confidencehave access to(to provide timeand delivery syteam care) 77. Improving PerOverall findingsthe enrollmentteamwork, imppatients. Also most time constackled first 72 . On the other hathe importance The coaching olevel of several self-managemepaper to electroEngaging cons
92S
ennsylvania (SEP
are is seen as vermbursed as thesbetes control. Als, 17 organizatio
a success. It and spreading 76. Performance me
chnology a promising tool inal. state that inramework during s health system goals), community), self-managemee to self-manage),o evidence-basedely access to datystem design (to
rformance in Pracs of IPIP show that in the PA chrproved communicefficiency has besuming aspects a
and, patients also of self-managem
of IPIP lead to poscommon complic
ent 87. A challengonic records. sumers
PA) implementat
ry positive and case activities had lso the way the ns around the st
provided a b
easurement
n the delivery of cntegrating innovadelivery can be (to serve as thety (to link with coent support (to he decision support
d guidelines), clinta about patients
restructure med
ctice (IPIP) at practices give dronic care initiatcation between heen improved in and work that rais
realize the changment and participasitive results in pacations related to tge remains rega
tion of the chron
are management aa high potential payment went
ate, who investedbetter understan
hronic care manaative technologycost-effective on foundation by pommunity resourelp patients acqut (to assure that pnical information and patient popuical practices to
different patient cative, such as enhealth professionseveral practicesses most annoya
ges in healthcare ted in group eductients with diabetethis disease as werding the transiti
Chronic car
nic care
activities to have and the d in this ding of
agement. as an
several providing ces and ire skills
providers systems
ulations), facilitate
are after nhanced nals and s as the ance are
and see cation 72. es at the ell as on on from
DSbdmImSprecafrureaacatothteTTatoTmta
e
DYNAMIC Stuckey et al. hypboth improve selfdiabetes. They stmanagement couldmproving healthSochalski et al. fouperson communiceadmission days
care managemenadded to residencrom acute illnesunderstood througegular assessme
and ready accessand social workercomponents (deprare necessary to ogether. Throughheir patient’s diserm outcomes whTEAMcare TEAMcare is a sapproach works toogether a step-byThe patient receimonitors the patiearget goals are no
pothesized that ef-care and reductate that when pd be translated to
hcare delivery und that the pract
cation had significthan when usual
nt of chronic discy training programs care towards
gh the CCM that ents of clinical, bs to other resourrs. Awareness is ression) in chronicbe acknowledgedh this acknowledease, encourage
hile decreasing ris
successful approao manage chroniy-step plan with aves specific coa
ents’ complaints. Tot reached.
enhanced nurse cce emotional distproven effective
o other chronic illn
tices using multidcantly fewer hosp care was provideease was seen ms. Furthermore, chronic diseasepatients need tim
behavioral, and prces such as pharaised that the unc ill patients, suchd and that chronicdgement cliniciane self-managemensk factors for addit
ach to chronic caic diseases. A nuachievable goals
aching by a nursThis nurse collab
case managementress for patientsimproved nurse esses 80.
isciplinary teams pital readmissionsed 81. Improvemewhen educationthe focus slowly care. It was fu
me with their provpsychosocial variaarmacists, nutritionderlying psychosh as diabetes patc diseases come s can better mant, and improve tional co-morbiditi
are. This collabourse and patient
to reduce complse care managerborates with the G
41
nt will s with
case
or in-s and ent on was shifts
urther iders, ables, onists, social tients, often
anage long-
ies82.
rative make aints.
r who GP as
42
Multifaceted dAfter the three in the CCM intmanagement insupporting theeducation progrAligning financTeam-based trClinical indicatoimproved in theseen in Body Mdid not showexpenditures inthe hospital-basfound in paymeIt was discussecare improved that better lifFurthermore, itcare managemesavings are noMedicare receivon CCM 85. Cost-effectivenLooking at the with usual caremodel is used 8
iabetes care inteyear follow up, suervention group on terms of self me effectiveness oram 83. ce & Insurance reatment for Medors as Hba1c, Boe intervention gro
Mass Index. Usingw a significantlyn comparison withsed outpatient vis
ents of the intervened that this except
without an increafestyle managemt is found that thent has improved
ot yet clear, but tve more value for
ness of CCM in acost-effectivenes
e shows to be e86.
ervention ustained improveon several biologmonitoring of blooof the used dia
dicaid enrolleesody Mass Index aoup. In both groupg an intervention by lower total Mh the control grousits. Here a small ntion group 85. tional improvemenase of costs in c
ment may have ough short-term for the better of tthe results show r their dollars due
a military settingss of a diabetes oeconomically rea
ments could be ogical aspects and od glucose. The abetes self-mana
and blood pressups, a small drop cbased on the CCMMedicaid and Mup at all levels ex
significant reduct
nt of BMI is notewcare. It was hypot
been the bigsavings are unlikthe patient. The lopayers as Medicto the interventio
g outreach clinic co
asonable when th
Chronic care
observed on self-latter is
agement
ure were could be M model Medicare xcept for tion was
worthy as thesized driver. kely, the ong-term caid and on based
ompared he CCM
1IntoCppdre•
•
•
•
•
•
e
1.7.7. Summaryn 2007 the Pennso effectively implChronic Care Modplan includes a nprovide transparedevelopment of seform; A public-pr
organizationsgovernment a
In 2008 moredemonstrationimprove patParticipating the implemen
The implemestimulated in a
Engagement culturally com
Preliminary reand performachange, teapatients, healt
Challenges repractices, andto prevention.
y sylvania Departmlement chronic ddel and the patienew way of care d
ency in health qstatewide health
ivate partnersh, health syste
agencies was creae than 150 primn program aimingtient outcomes practices receivetation of the new
entation of informall elements of theof patients take
mpetent health eduesults are positiveance of self-manmwork, communth outcomes and emain regarding pd the inclusion of
ment of Health lauisease managemt centered medicadelivery and orgauality, changes information exc
hip including ems, educationated for that purpoary care practice
g to deliver proactwith diabetes
e support servicesmodel of care del
mation technologye Chronic Care Mes place via inucators; e: improved patienagement, profesnication betweencost savings for thpractice change, more diseases a
KCE Report 1
nched a strategicment by combininal home. This straanization, new lawin scope of pra
change, and pay
insurers, healthnal institutions ose; es were enrolledtive, planned care
as target diss in order to suclivery; y in diabetes ca
Model; tensive educatio
ent’s attitude regassionals’ readinesn professionals he highest risk grodissemination to
and expanding to
192S
c plan g the ategic ws to
actice, yment
hcare and
in a e and ease. cceed
are is
on by
arding ss to
and oup; more focus
KCE Reports 19
1.8. FutureIn this section fof the four coincluded literatu
1.8.1. FutureIn redesigning cbeen paid to cawith COPD andimprovement swith other chrofrom national ilimitations of increasingly attStandards of Coriented standaThe evidence Netherlands is aim to supporegarding chronbundled paymediabetes in thediabetes care. integrated careconstructions’ (bundled paymethe researchersbundled paymCommittee of IHealth on theexperimental pevaluations meDISMEVAL. Thcountries, incluNetherlands is groups (over
92S
e Actions in thefuture actions reg
ountries or regionure.
e Actions in the Nchronic care in thare for diabetes pd vascular risk matrategies. It is un
onic disease, suchncentives for quasingle disease
tention is paid to Care is preparingards and redesign
base for chronlimited. A few larrt policy makersnic care management stimulates the e Netherlands and
The evaluation e: the potential f(claiming fees for ent agreements). Ts was to harmonent arrangementntegral Financinge status of thehase comes to aethods for diseahis project focusuding Denmark atesting two evalu
106,000 patie
e 4 countries garding chronic cans are presented
Netherlands he Netherlands firspatients. In a lateanagement were ncertain, if and wh as heart failureality improvemen
oriented appromulti-morbidity.
g a strategy to strategies.
nic care improverge scale based ss in making be
ment. The first repimplementation od as such, a mo
also showed ufor double insurar diabetes serviceTherefore, one of nize the existing ts 26. In 2012,
g of chronic care we bundled paymn end. The develse management es on existing pand the Netherlauation designs onent), which hav
are improvement d, as retrieved f
st and most attener phase care for object of similar,
when the care for and dementia, wt. The awarenesoaches is raisiThe National Plaintegrate single
ement strategiesstudies are underwetter informed dport of RIVM reveaof the standard of ore systematic deundesired side-efance claims and es in circumventiof the recommendapricing mechanisthe National Ev
will advise the Miment scheme onlopment and valid
is one of the projects in six Eands. DISMEVAL data of 18 regiove contracted
Chronic car
for each from the
ntion has patients national
r people will profit s of the ng and
atform of disease
in the way and
decisions aled that care for
elivery of ffects of ‘bypass
on of the ations by sms with valuation nister of nce the dation of aims of uropean
L in the onal care
disease
mRainlaDbfeimdpmD
1Tinm(gscasmginohaNsSEpo
e
management for dResults from DISMal. are conductingnitiatives in the Narge scale implemDutch regions betbetter understandeasibility, and comprove health cadisease managempolicy developmenmakers and manDisease Managem
1.8.2. Future AcThe National Boarn chronic care mmanagement, orgguidelines, DMPs
systems. The focuchronic condition tand rehabilitation.stimulate this. Fumanagement shougood coordinationnterdisciplinary wother health care whappen. Here, thactive self-managNational Board strengthen informaSome of these reEvaluations of thepresent their findinobtained on imple
diabetes by meanMEVAL will becomg an evaluation
Netherlands. The mentation of disetween 2009 and 2ding of the mechst-effectiveness o
are and the factorment programs. Wnt, the study of Lenagers during thment Programs int
ctions in Denmard of Health ment
management 36. Figanization of cars), supportive co
us should be on eto maximize his/h. Patient educatio
urther, adaptationuld be taken into n with sectors a
working, drawing oworkers, in collabe local communigement and shoof Health mad
ation collection meecommendations se projects, initiatngs in 2013. Enhaementing program
ns of the bundledme available in 20study regarding objective of this
ease managemen2011. The aim ofhanisms of diseaof a disease manrs that determine Whereas DISMEVemmens et al. willhe implementatioto the health care
ark tions several imprirst, the focus shre, use of decis
ommunity and ponhanced support er self-care potenon models and r
n to special needaccount, such as
and across regioon the professionboration with GPs ity should motivaould facilitate hee also recommethods 7.
have been conted by the Governanced insight andms based on the
d payment schem012. Also Lemmedisease managestudy is to evalu
nt programs in vaf this study is to ase managementnagement approasuccess and failuVAL will contribul be of use for decon and integratio
system 22.
rovements to be mould be more onsion support sysolicy framework oof the individual w
ntial, through educregional networksds of chronic diss primary care seons. More suppoal skills of nurses and patients nee
ate patients to puealthy lifestyles.
mendations aimin
verted into progrnment, are expectd understanding w
CCM. Given tha
43
me 31. ens et ement uate a arious get a t, the
ach to ure of ute to cision on of
made n self-stems or IT-with a cation s can sease etting, ort of s and eds to ursue
The ng to
rams. ted to
will be at the
44
results from thefuture are baseHowever, studprimarily been between sectorsystem. The gcultural barriersof the problem.methods whichNetherlands, exmethods to suppractical and reon-going monitomeasures needquately 8. Critemethods have bspecific purposmanagement acare and ultima
1.8.3. FutureIncreased supplead to integratethey will have physicians 59. Hlittle standardizstroke care exithat disparities ongoing particiexpected to facmembers (cliemakers. In addition to thneeded of the important comprofessional ed
ese evaluations ad on the experienies on integratedcase studies idenrs and describinggaps are typicallys 8, but it would be Furthermore Stra
h are used are rexperts in Denma
pport chronic careelatively simple tooring conducted bd to be developederia for the develobeen suggested. Ae can be useful tnd continuous res
ately to the benefit
e Actions in Quebport from the goved care. A specia
to recruit and However, as was szation or systemst 62. By developin care and hea
ipation of Heart cilitate timely, bi-dnts, clinicians, i
he improvement ovalue and effica
ponents 63. Alsoducation of healt
re not yet availabnces with existing d healthcare serntifying problems
g disease specificy described as re interesting to inandberg-Larsen pelatively resourcerk focus on the a
e management. Ao use, especially fby health system pd for areas that aopment of existingA range of broadlto both evidence-search efforts witt of the recipients
bec vernment and re
al role is seen for tmobilize efficienseen in a specific
matization with reing more standarlth-related qualityand Stroke Que
directional commnvestigators) an
of integrated careacy of team-delivo, actions are rth human resour
ble, actions for theprograms in Denmrvices in Denmaof information ex
c gaps in the hearelated to structuvestigate the wide
points out that thee-intensive. Similaapplicability of evn ideal method shfor non-scientific planners. In additare as yet covereg and new measly validated methobased healthcarethin the field of inof care 9.
egional authoritiesthe regional authot clinical staff, i
c case of stroke caespect to approardized tools it is ey of life will improebec within the unications betweed decision- and
e also further insivered healthcare required on morrces and more
Chronic care
e nearby mark.
ark have xchange alth care ural and er range e current ar to the valuation hould be use e.g. ion, new d inade-urement ods for a e system tegrated
s should orities as ncluding are, very aches to expected ove. The MSN is en MSN policy-
ghts are and its
re inter-practical
inHekcFdcefoGcctoeocth
1FCsoreSaomuoidreAA
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nformation systemHollander et al.enhanced collaboknowledge transfecaregivers for patiFurthermore, it isdelivered care. Pconsidered as teaensure a shared por decision makinGogovor et al. mecauses of care gclinical, humanistico disease manageconomic impact oof the reviewed pcare managementhe health system
1.8.4. Future acFuture actions folChronic Care Initistatewide results organizations will egarding the prim
Second, the SEPAand fully assess thof the possibilitiesmanagement feesutilizations, efficienof this initiative wildentifying the higesources and ma
Also the multifaceAccording to Piatt
ms have to becmention the par
oration with profeer could act as ents with chronic s believed that Patients and no
am members and perspective of conng to patients 66. ention the need toaps and greater c and fiscal outcogement structureof project should bprojects has evalt. As this is an in58, a focus on this
ctions in Pennsylow from three dative/IPIP will beof financial inveprovide direction
mary care paymentA project needs he impact of the is in payment is a to shared savingncy, cost and quall be mapped in a ghest-cost individking care manageted diabetes caret et al. it is impo
come available torticular requiremeessional provideran important toodiseases 88. the focus should
on-professional cfoster understan
ntentious issues s
o increase knowleconcentration onmes in compariso
es and processesbe taken into consuated the econo
ncreasing area ofs type of informati
ylvania ifferent projects.
e available in 3 yeestment by insure on future steps t system for residto continue monimprovements in cshift from per-me
gs, and a combineality of care. Also f
future evaluationduals, making moement a daily route intervention focuortant to understa
KCE Report 1
o all stakeholdeent of and desirrs. In the near fol for non-profess
d be more on tcaregivers shouldding of team theosuch as shifting p
edge of the unden the measuremeon with the causals 58. Also, the gsideration. So far mic impact of chf interest for payeon is desirable.
First, results fromears from now. Ters and several that need to be ents of PA 72. itoring the interveclinical paymentsember per-month
ed focus on healthfacilitators and ba. Focus will be pa
ore use of commtine 76. uses on future ac
and if improvemen
192S
rs 66. re for future sional
team-d be ory to power
erlying ent of l links global none
hronic ers in
m the These other taken
ention . One
h care h care arriers aid on munity
ctions. nts in
KCE Reports 19
outcomes are multifaceted diadeliver what cdiabetes 83. Third, Scanlontreatment for immediate costmight be expeunderline the imchronic care purchasers (incbelieve in cost r
1.9. DiscusIn this study thNetherlands, D(Quebec) are delements of thecare was collecof experts from creating a regiounderstand the of redesigningchronically ill. The three strathealthcare systto support clinstrategies are: • direct supp• changes t
conducive • consumer e
purchasingEach of the stratransforming c
92S
sustained and abetes care intervcare to whom w
et al. report onMedicaid enrollet reduction effectsected from this importance of appmanagement ini
cluding those in threduction at the s
ssion he policies for imDenmark, the Undescribed and coe CCM. Data on pcted by means ofthe selected cou
onal healthcare sways in which the healthcare sys
tegies or pillars tem will all benefiical care and for
port of practices ato benefits and to system changeencouragement o
g 2. ategies are aimedcare i.e. consum
what type of ventions. A Better
will reduce the p
n the possible sees. Although ths, it was reasonentervention. In splying a long termtiatives, given t
he Medicaid and Mhort term 85.
mproving the qualinited States (Penmpared in terms policies for improvf a literature searcntries. By makingsystem 2, an attee selected regionsstems in order
of the frameworkt from the poolingr performance me
nd active programprovider paymen
e, of cost-effective ca
d at one of three kmers, providers,
patient profit mr understanding oproportion of adu
avings from teamhis study did noed that long-term so doing, Scanlom focus when evthat policy makeMedicare program
ity of chronic carnnsylvania) and of the implemen
ving the quality ofch and with the g
g use of the frameempt was made ts act upon the chto meet the ne
k for creating a g of clinical and ceasurement. The
ms of practice chant to make them
are through advoc
ey sets of stakehoand purchaser
Chronic car
ost this of how to ults with
m-based ot show savings
on et al. valuating ers and
ms) often
re in the Canada tation of f chronic guidance ework for to better allenges eeds of
regional cost data ese three
nge, m more
cacy and
olders in rs/health
incea
1Aimthdh
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•IninpcTinininw• TreHthrethhisreaho
e
nsurers 2. The frachronic care manengaging consumaligning benefits a
1.9.1. ImplemenAs a result frommprove chronic che six areas ofdecision support, health care organi
1.9.1.1. Health s
The Netherlann 2008 the Dutch n terms of the propackage of varioucure and care) of To implement tntroduced on natntegrated care fonitiatives are stimwithin local neighb Denmark The Danish Minisegarding chronic
Health Throughouhe role of healthegarding chronic he strengthening healthcare and sos made of a genehabilitation prog
and personal acthealth centres. Vaorder to improve
amework describenagement within mers, supportingand payment 2.
ntation of the elem developing and
are managementf the CCM gain
delivery systemzation, and comm
systems: organiz
nds Ministry of Health
ogrammatic appros phases (prevena continuum of c
the programmatitional level: qualitr diabetes, COPD
mulated against tborhoods including
stry of Inferior anc care in multipleut Life. Important hcare providers acare on regional of their ability to
ocial context. To ineric model for crams for diagnosion plans and imarious incentives
the quality of c
es four interrelateda region: perfor delivery system
ements of the Cd implementing , it can be conclu
n attention: self-mm design, clinical munity resources.
zation of healthc
h revealed a new oach for chronic
ntion, self-managecare for patient wic approach twty measures and D and vascular risthe vision of redg an important rol
nd Health has laide documents e.g
policy issues areand their collabolevel and the roleo promote one’s improve chronic chronic disease ped patients, inclu
mportant roles fohave been introd
chronic care. Ex
d strategies to imrmance measurem improvement,
CM multiple strategie
uded that most or management sup
information sys
care
vision on chroniccare i.e. an integ
ement, evidence bwith a chronic diswo instruments
bundled paymensk management. designing chronic e for primary care
d down its policy g. the Health Acte the strengtheni
oration and cohere of patients in ter
own health withicare managemen
pathway programsuding self-manageor GPs and munduced in the systexamples of these
45
prove ment,
and
es to all of
pport, tems,
c care grated based ease. were
nts of Local care
e.
aims t and ng of rence ms of n the
nt use s and ement nicipal em in
e are:
46
financial incentincentives throu• Québec Notwithstandingsince the 1970primary care fragmentation aorganizational ehospitals and lcentres or locmedicine group• PennsylvanIn 2007 the Peto effectively imChronic Care Mplan includes aprovide transpdevelopment oreform. For thisorganizations, agencies was c
1.9.1.2. ClinicIn the Netherlanway in order totakes place reglocal level. In facilitate a moreacross organizaon national levfailure. Also inregarding chronsometimes paimplementationall elements of
tives for GPs andugh benchmarking
g the existence o0s, disease manpractices were
and to increase expansion took pong-term hospitaal health networ
ps. nia nnsylvania Depar
mplement chronicModel and the pata new way of cararency in health
of statewide heas, a public-privatehealth systems,
created.
cal information snds first attempts o measure perforgarding diabetes
Denmark a nate systematic and ations. Until so fa
vel for eight disean Quebec performnic care managemart of telehealt of information tethe Chronic Care
d municipalities, g.
of integrated delinagement progra
introduced in the accessibility lace when local cls merged into hrks which nowad
rtment of Health c disease managient centered medre delivery and o
h quality, changealth information ee partnership inclu
educational inst
systems are made to colle
rmance. Performamanagement on ional strategy wadisease related d
ar, performance mase including COmance measuremment takes place th experiments. echnology in diabe
Model.
and quality impro
very systems in ms and multidisorder to diminof chronic care.
community centreealth and social days also include
launched a strategement by combidical home. This s
organization, new es in scope of pexchange, and puding insurers, heitutions and gov
ect data in a standance measuremean experimental as launched in
documentation of measurement takeOPD, diabetes, anment and data c
on project base In Pennsylvan
etes care is stimu
Chronic care
ovement
Canada ciplinary
nish the Further
es, acute services e family
egic plan ning the strategic laws to
practice, payment ealthcare vernment
dardized ents only base on 2007 to services es place nd heart
collection and are
nia the ulated in
1IncpInfi
1InoTIncinreInmainIndaPim
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e
1.9.1.3. Decisionn the Netherlandscare standards in programmatic appn Denmark, Queilled by means of
1.9.1.4. Deliveryn the Netherlandorder to strengtheThis is getting shan Denmark theconsequence the nteraction with eesulted in the intron Quebec initiativmultidisciplinary taccessible, compnitiatives financialn Pennsylvania mdemonstration proand improve paParticipating practmplementation of
1.9.1.5. Self-man the Netherlandnational care stansuch a plan. n Denmark, the CDSMP) has beeor patient involvemIn Pennsylvania education by cultu
n Support s a lot of effort isorder to support
proach and redesigbec and Pennsylprofessional guid
y system designs the role of primn its activities reg
ape by the developre is increasingrole and compe
each other and woduction of for ex
ves are launched teams or networehensive, ongoil incentives were c
more than 150 priogram in 2008 aimatient outcomes tices receive supthe new model of
anagement suppds, individual treandards, however o
Stanford Chronien introduced on ment.
engagement ofurally competent h
s spend in the det healthcare provign practice. vania decision suelines.
n mary care receivegarding the organipment of care grog attention for etencies of healtwith patients hasxample shared dec
to redesign primark organizations ng and personacreated. imary care practicming to deliver p
with diabetes pport services in f care delivery.
port atment plans areonly a minority o
c Disease Self-Mnational level, to
f patients takeshealth educators.
KCE Report 1
evelopment of naders to implemen
upport is mainly
es specific attentiization of chronic
oups. lifestyle changeth professionals,
s been examinedcision making. ary care and to c
in order to prlized care. For
ces were enrolledroactive, planned
as target disorder to succee
e promoted as paf patients has ac
Management Proestablish a frame
s place via inte
192S
tional nt the
being
ion in care.
s. In their
d and
create rovide these
d in a d care ease. d the
art of ctually
ogram ework
ensive
KCE Reports 19
1.9.1.6. CommIn the Netherlachronic care iscommunity at thQuebec has beimprove and multidisciplinarycare.
1.9.2. OutcomIn all four count• In the Net
chronically outcomes o
• In Denmarfor integramodest impof compete
• In Quebeimplementaachieved Simultaneoreduction iphysiciansincreased costs.
• In Pennsyattitude professionabetween psavings for
92S
munity: resourceands, Denmark ans put on the heahis moment. een implementing
integrate healty team-based pra
mes of redesigntries only prelimintherlands results r
illness show of care. k results have rev
ated care deliverpact of healthcareencies among GPec reforms are ation phase’ givand clinical in
ously, results shin hospitalization , satisfaction ouse of telehealth,
lvania preliminaryregarding and als’ readiness professionals anr the highest risk g
es and policy nd Pennsylvania ealth system with
regional communth and social
actices in primary
ning chronic careary results have bregarding the impmodest improve
vealed solutions tory (e.g. financial e centres on healts to coordinate pr
characterized ven that structurntegration still ow improvementrate for elderly,
of patients and involvement of n
y results are posperformance
to change, tead patients, heagroup.
emphasis for redmodest initiative
nity centres to cooservices as w
care to reinforce
e management been presented unpact of integrated ements in proce
o overcome mainincentives and
th outcomes, and rimary care netwoas ‘being still
ral integration isbeing in its
t regarding acce improved knowl
d healthcare prnurses and no inc
sitive: improved of self-mana
amwork, commulth outcomes a
Chronic car
esigning s in the
ordinate, well as primary
ntil now. care for
ess and
barriers HIT), a the lack
orks. in its
s mostly infancy.
essibility, ledge of roviders,
crease in
patient’s agement, unication nd cost
1
•
•
•
•
InreqppH•••
•
e
1.9.3. Barriers i
In the Netherare identified providers, fragCare Model proactive patie
In Denmark manage the regarding actu
Challenges inmanage the regarding actu
In Pennsylvadisseminationand expandin
n all four regions edesign seems t
quality or efficienpurposes only. Clprovider record syHowever data coll to provide a fe for financial in for the purch
payment and for consumers
receive care 2
in redesigning ch
rlands barriers fo(e.g. lack of inc
gmented primary which are underents). challenges remwhole patient
ual change, and dn Quebec are the
whole patient ual change, and dania challenges
n to more practiceg to focus to prevthe systematic c
to be troublesomcy are generally inical data on ind
ystems. ection is required eedback to the proncentives, hasers and insurquality improvems: to have access2.
hronic care man
r implementing incentives, lack of care) as are com
rdeveloped (ICT,
ain regarding apopulation, org
data collection. e development of
population, orgdata collection. s exist regardines, and the inclusvention. collection of meanme. Currently, ag
missing or get dividual patients r
: oviders on their p
rers to have accent activities;
s to their medica
nagement
ntegrated chroniccollaboration betponents of the Chcoordination of
n overall strateganizational read
an overall strateanizational read
ng practice chasion of more dise
ningful data in ordggregate measurcollected for resereside in disconn
erformance,
cess to data to
l record wherever
47
c care tween hronic care,
gy to diness
egy to diness
ange, eases
der to es of earch ected
guide
r they
48
1.9.4. LessonThis study shointroduced regastrategies of thmore general, aregions. • Policies r
strategies motivation (e.g. collabthe building
• Strategies redundancpayment. Itransformaimprovemein the Neth
Practices redesof care and theall four regionredesigning chrpolicy makers laThe CCM is nframework withfor change intochanges assocto organizationredesigning chchanges acrossIn all four regioAccording to measurement, improvement, afurther research
ns learned ows that in all foarding the three
he framework for a shift towards co
regarding provid(e.g. standards and support of p
boratives and/or pg of clinical data s
for insurers aimies and inefficiedeally, these sho
ation of care, espent. The experimeherlands is an exasigned in accord we outcomes for pans the building ronic care manageack adequate infonot a discrete, imin which care del
o specific applicaciated with a particn and from couhronic care manas multiple elementons, chronic care
the authors, engaging con
and aligning benh is necessary to s
our regions multistakeholders ancreating a region
onsumer involvem
ders encompass of care, evideroviders to redesiphysician networksystems. m to remove somencies in currenould reduce costspecially if accoment regarding the bample of such strawith the CCM genatients with variou
of evidence reement has only ju
ormation to take dmmediately replicivery organizationtions 89. As a rescular CCM elemeuntry to country.agement in accots of the CCM. management remthe four strate
nsumers, supponefits and paymeshed light on this
ple policy measud consequently anal healthcare syment was found in
s quality improence based guidign their delivery ks) and to a lesse
me of the disinct health insuran
s as well as encopanied by incentbundled payment
ategy. nerally improve theus chronic illnessegarding the imust started. Conseecisions.
cable interventionns translate genersult, the specific
ent vary from orga Furthermore, p
ord with the CCM
mains work in progegies (i.e. perfoorting delivery ent) are synergist
question.
Chronic care
ures are all three stem. In
n all four
ovement delines), systems
er extent
centives, nce and ourage a tives for scheme
e quality ses 89. In mpact of equently,
; it is a ral ideas practice
anization practices M make
gress89. ormance
system tic 2 but
e
KCE Report 1192S
KCE Reports 19
REFE
92S
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re quarterly, 2009
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new
54
2. OVERVThis appendix dproposed by theFor each report
2.1. QualitQuality and or
The full report cRecommendati• Transition
secondary/t• Patient-emp
synchronize• Transition t
(domain tai• Central role• Crucial role• Provision o• Definition o
patients to • The develo• The develo
clinical info• Developme• Existing ini
(domain tai• Financial su
VIEW OF Kdetails the recomme chronic care mot the interested re
y and organizarganization of typ
can be found on: hons for national pfrom symptom-fotertiary preventionpowerment and sed interventions totowards primary lored delivery sys
e of GP (and prime of diabetes educf education in dia
of role of diabetesa specialist (domapment of shared c
opment of a polyvarmation systems)
ent of systems for tiatives must be lored delivery sysupport for teams w
KCE REPOmendations from odel. ader can find the
ation of type 2 dpe 2 diabetes car
https://kce.fgov.bepolicy: ocused care to n of complicationssupport from relao support the paticare multidiscip
stem design) ary care setting) a
cator (recognition betes care for ress-specialists: coaains appropriate wcare protocols witalent clinical infor
quality monitoringreplaced by natio
stem design) with activities outs
ORTS the main KCE re
scientific report a
diabetes re (KCE-27-2006)
e/publication/repo
global proactive,s (domain tailoredatives: process cent (patient educa
plinary team (in c
and integration of in Belgian law) (d
sidential staff (domaching and traininworkforce and quathin the multidisciprmation system an
g and evaluation (onal initiatives wit
side the traditiona
Chronic care
ports on chronic c
and related conclu
)
ort/quality-and-org
, patient-focused delivery system d
criteria for treatmations, intensive focollaboration with
diabetes care in domain appropriatmain appropriate wng of all membersality processes) plinary teams (dond its accessibility
(indicators, standath a central comm
al fee-for-service s
e
care. All recomme
usions via the link
anization-of-the-c
and integrated design)
ment fidelity (regisollow-up) (domain circles, local dis
basic and postgrae workforce) workforce) s of multidisciplin
main quality procey for the health ca
ards and evaluatiomunication platfor
system (domain ap
endations have be
proposed in the ta
care-for-diabetes-2
care with patie
stration of the Gn self-managemenscussion platform
aduate education
ary team and de
esses) are providers (cru
on criteria) (domarm collaborating w
ppropriate financi
een classified into
ables.
2
ent education, sy
MD/DMG, frequent)
ms (LOKs/Glems)
(domains appropr
evelopment of gu
cial for integrated
ain quality processwith the existing d
ng)
KCE Report 1
o one of the categ
ystemic follow-up
ency of consultat
or diabetes netw
riate workforce)
uidelines for refer
d patient care) (do
ses) diabetes organiza
192S
gories
p and
ions),
works
rral of
omain
ations
KCE Reports 19
2.2. ClinicaClinical quality
The full report c
Recommendati
• Need for a • Identificatio
processes)Recommendati
• Objectives • Need for v
registration• High qualityEfforts on level
2.3. Medic
Medication use
The full report cRecommendatiRVT formulary: • measures s• larger role o• pivotal role
quality cont• close collab• provision of
associated Generic drugs (
92S
al quality indicay indicators (KCE
can be found on: h
ons:
clear vision and don of priority area
ons for developm
and use of QI: devalid and comple and feedback y evidence: imporof clinical excelle
cation use in nu
e in nursing hom
can be found on: hons: should be taken toof medical coordinof formulary in k
trol systems (domboration with scienf evidence summawith drug utilizatio
(domain decision
ators E-41-2006)
https://kce.fgov.be
development of stras that need qua
ment clinical quality
ecided and explicitte database: sta
rtance for developence and on level
ursing homes
mes (KCE-47-200
https://kce.fgov.be
o increase implemnator (domain appnowledge transfe
main quality procesntific, professionaaries on appropriaon in elderly (domsupport):
e/publication/repo
rategy about qualality monitoring (b
y indicator (QI) sy
t in advance+ neundardized registr
pment of QI+ transof resources nece
06)
e/publication/repo
mentation and imppropriate workforcr of best practicessses) l associations (doateness by indepe
main clinical inform
Chronic car
ort/clinical-quality-i
ity policy in healthbased on explicit
ystem (domain qua
utral evaluation of ration methodolog
sparent involvemeessary to initiate a
ort/medication-use
pact (domain qualice) s towards prescri
omain tailored deliendent drug informmation systems)
e
indicators
h care (domain tat health objective
ality processes)
consequences ongy and data ana
ent of clinical expea credible and pro
e-in-rest-and-nurs
ty processes)
bing physicians a
ivery system desigmation and pharm
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n quality of healthlyses + timely fe
erts (final selectioofessional quality s
ing-homes-in-belg
and in local implem
gn) macovigilance cent
stem design) red delivery syste
h care eedback to its us
n and formulationsystem (domain q
gium
mentation of pres
ters and increase
em design and q
sers + coordinati
QI) quality processes)
cription guideline
e of awareness for
55
quality
on of
)
s and
r risks
56
• local agree• investigatioMedical staff: (d• better traini• clinical phaFinancing syste• exploration
2.4. ChronChronic low ba
The full report cRecommendati• Need for aw
evidence in• It is crucial • Close coop• Current dat
2.5. PersoPersonal contr
The full report cRecommendatiTransparency: • Large varia• Clear regul• More transpProtection mec• Actual syste
ments could increon of possibilities fdomain appropriating in pharmacolormacists should a
em (domain approof other financing
nic low back paack pain (KCE-48
can be found on: hons on: wareness of all ca
n favor of certain cto get patients ba
peration needed bta sources are too
nal contributionribution for healt
can be found on: hons on: (domain appropria
ation in supplemenation necessary oparency in price shanisms: (domainem of MAB only p
ease their use for applying unit-dte workforce)
ogy of nursing stafassist and participopriate financing)g systems, beside
ain 8-2006)
https://kce.fgov.be
are providers on conservative treatack to work as quietween occupatio
o fragmentary
n for health carth care in Belgiu
https://kce.fgov.be
ate financing) nts affects patienton the data collectsetting (also for then tailored delivery protects for high o
dose (packaging p
ff and enhanced cpate in all stages o
es fee-for-service
e/publication/repo
the dangers of inments and the abckly as possible
onal physicians an
re in Belgium. m. Impact of sup
e/publication/repo
’s choices tion on supplemene ambulatory caresystem design)
out-of-pocket paym
Chronic care
per individual patie
communication caof medication use
system, such as c
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activity among pabsence of such da
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Impact of supppplements (KCE-
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ments, not for sup
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an improve the quprocess
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atients, the uselesata for many other
he curative sector
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bution-for-health-
plements
ality of pharmace
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ssness of applyinr applied intervent
r
care-in-belgium-im
utical care
pricing
g multiple diagnotions
mpact-of-supplem
KCE Report 1
ostic procedures, t
ments
192S
the
KCE Reports 19
• Duration of • Better prote• Regulation • Be aware o• Regulation Supplemental hClear regulatio
2.6. ChronChronic care o
The full report cRecommendatiResidential care• Need for sp
staff and ad• Age-base c• The conver• Support fo
psychic/psyResidential care• Specific un• Evaluation • Developme• Creation of • Specializati• Expand NIHHome care: (do• demand for
92S
f hospital stay musection of patients wshould make a cl
of social stratificatiof supplements in
hospital insuranceon necessary to
nic care of persof persons with a
can be found on: hons: e: (domain tailorepecific units for ydapted infrastructucriterion in order torsion of RVT/MRSor the staff for ychiatric/cognitivee for specific subgits for persons witof these units via
ent of supportive nf permanent stay iion of certain instiHDI-convention foomain tailored delir additional profes
st be taken into acwith recurrent hosear distinction beion in choice of ron ambulatory caree: (domain tailoredimprove accessi
sons with acquiacquired brain in
https://kce.fgov.be
ed delivery systemyoung persons witure o maintain the posS beds into ABI-bespecific compete problems groups: (domain tth severe behaviopilot projects
network for ABI-pen Sp-services for itutions in residen
or specific MS-cenivery system desissional support an
ccount in new prospital admissionstween indispensa
ooms, which coulde d delivery system ibility for everyb
red brain injurynjury between the
e/publication/repo
m design) th acquired brain
sitions for personseds in a limited nuences: organizati
ailored delivery syor problems in sma
ersons, staying in persons with sevtial care for perso
nters to all MS-patgn)
nd for temporarily
Chronic car
otection systems (
able and non-indisd lead to differenc
design) ody (domain tail
y between the e age of 18 and 6
ort/chronic-care-of
injury (ABI) (18-6
s <65y umber of geographion of modified
ystem design) all departments, s
other care sectorvere physical careons with a degenetients staying in ca
relief of the volun
e
in case of chronic
spensable costs es in quality of ca
ored delivery sy
age of 18 and 65 years (KCE-51
f-persons-with-acq
65y) with separat
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spread over Belgiu
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teer aid by respite
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57
petent
ort by
58
• Need for da• Demand foCoordination be• Recognition• Developme• Expansion
2.7. OrganOrganization a
The full report cRecommendatiRegulation: (do• Need for a Financing: (dom• Need for di
patient • Need for ge• Integration • Shift from 7Rehabilitation: (• The establi• “Stratificatio
rehabilitatio• The intake
medical diaage, contex
• Making theservices (be
• On short te
ay centers r more care optionetween different cn of specific experent of a network beof SEN (Steunpun
nization and finand financing of
can be found on: hons:
omain tailored deliglobal concept in
main appropriate ffferentiation of fin
eographically spreof monodisciplina
7/7 financing to 5/7(domain tailored dshment of three son model” for subon needs and incid
and referral of pagnosis, a measuxtual factors). e registration of thetter assessments
erm, systematic re
ns and individual-care settings: (domrtise centers etween centers nt Expertise Netw
ancing of muscmusculoskeleta
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very system desigBelgium
financing) nancing systems N
ead centers over Bary therapy under 7 or day hospitalizdelivery system despecialized centerb-acute rehabilitatdence/prevalence
patients in the sysurement instrumen
he medical diagnos of incidence and
egistration in post-
-based care (zorg main tailored deliv
werken) for ABI-pe
culoskeletal anl and neurologic
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gn)
Need for transpar
Belgium (determinthe supervision o
zation to promote esign) s for spinal cord ition with a generae. stem must be bant for the function
osis and co-morbid prevalence of re-acute phase with
Chronic care
op maat) very system desig
ersons (domain ta
nd neurologicalcal rehabilitation
ort/organisation-an
rency of financing
ned by the Conveof the rehabilitation
weekend stay at
njuries al, specific and hi
sed on a patient nal needs and po
idities on short-teeimbursement cath a measurement
e
n)
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rehabilitation in Belgium (KCE
nd-financing-of-mu
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ntions) n physician in the home
igh specific level,
classification sysossibilities of the p
erm mandatory, wtegories) instrument like F
stem design)
in Belgium E-57-2007)
usculoskeletal-an
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multidisciplinary t
organized in a n
stem (PCS). Thispatient and a cert
would be a progre
IM/Barthel-index i
d-neurological-reh
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treatment
etwork. Determin
s classification systain additional da
ss for the evaluat
is recommended
KCE Report 1
habilitation-in-
ion of the needs o
nants are complex
stem must includata (like co-morbid
tion of the provis
(both in hospitaliz
192S
of the
xity of
de the dities,
ion of
zation
KCE Reports 19
as in ambu• In evaluatio
the patient • The registra• Restart of t• The organiz• Estimations
centralized)• Proposition
on specific centers)
The differentiat
2.8. PhysicPhysician wor
The full report cRecommendati• Need to en• Role of the
made publi• complemen
productivity• Regular sur• Identificatio• The collecte
important toconsidered
• Need for thby sufficienMedical Su
92S
latory care) on of the quality oon quality of careation systems usehe visitation commzation of networkss on the number o). General rehabil
n of financing (domand high specific
ion in individual tr
cian workforce rkforce supply in
can be found on: hons: hance the coordin
e national Registecly available to st
ntary data collectiy (domain quality prveying (quantitat
on and monitoring ed data must feedo evaluate the un, such as the effee development of
ntly reliable informpply Planning sho
of the organization etc.
ed in other countrimissions is recoms for the continuityof rehabilitation ceitation must be br
main appropriate fc level a mixed sy
reatment and grou
supply in Belg Belgium: curren
https://kce.fgov.be
nation and harmoer of the Medical akeholders and reion needed for mprocesses, approive and qualitativeof indicators on h
d the forecasting ncertainty of the ctive demand-basf a national workfo
mation and robustould be empowere
nal and financing
ies could be an exmmended y of care enters: 20-30 on sroadly accessible financing): on gen
ystem with partly a
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gium: current sint situation and c
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nization of routineProfession: data esearchers (doma
more specific inforpriate workforce)e) of a sample of health needs, sucmodel so as to remodel by determsed approach whiorce planning fram methodologies) aed for this role as
Chronic car
system must be
xample for Belgiu
specific level, 3-5 (via acute hospita
neral level a fee-foa fixed financing a
commended (also
tuation and chchallenges (KCE
ort/physician-work
e data collection oon head counts,
ain clinical informarmation on practic
health care practih as disease trend
eflect as much as ministic sensitivity
ch accounts the hmework, which woand evolutive (fledeveloper of a na
e
taking into accou
m
on high specific leals) or-service or a miand partly fee-for-
on the level of ra
allenges E-72-2008)
force-supply-in-be
on the ‘stock and factual level of ac
ation systems, tailce arrangements,
tioners (similar tods or new clinical possible the systeanalysis or stoch
health needs and ould be integratedexible and adaptivational framework
unt the outcome o
evel (in which the
ixed system with -service financing
te) (domain tailore
elgium-current-sit
flows’ of the medicctivity, attrition or lored delivery sys, workload indica
the Netherlands management (do
em as a whole anhastic simulation. the economic par
d, consistent and eve to rapidly chank. (domain approp
of treatment, quali
e rehabilitation of c
relative high fee-f (or envelope fina
ed delivery system
uation-and-challe
cal supply (domaimigration rate shtem design) tors or certain de
and France) (domomain quality procnd to produce use
Other types of mrameters.(domain evidence-based (
nging health systeriate workforce, q
ty of life, percept
complex patholog
for-service compoancing for high sp
m design)
nges
in quality processhould be validated
eterminants of me
main quality procecesses) eful scenarios. It ismodels should alsquality processes
decisions are infoem). The Committuality processes)
59
ion of
gies is
onent, pecific
es) d and
edical
esses)
s also so be s) ormed tee of
60
2.9. FinancFinancing of th
The full report cRecommendatiDefinition and id• Definition o• Screening: • IdentificatioInternal liaison • Screening w• The demen• Every patie• The liaison • The liaison • The liaison • Need for a • Need for seFinancing instru• APS instrum
data and imProposition to r• Conditions:Reformations: cfinancing of sta
cing of the carehe care program
can be found on: hons: dentification of ge
of SBGG-BVGG ISAR (version of
on of geriatric probgeriatrics (liaisongwith measuremennted patient in a nuent, identified as g
nurse reports dainurse plays an acteam consist of amore decentralize
ensitization for geruments (domain ament most approp
mplementation) reform financing o additional resear
collection of additff on the acute ge
e program for gm for geriatric pat
https://kce.fgov.be
eriatric patient: (do
BGMST), SHERPblems: BGMST geriatrie) (domain
nt instrument of eaursing home and eriatric, must be sily to the geriatristctive role in the di
a geriatrist and at ed model for geriariatric culture
appropriate financpriate (most valid
of acute geriatric drch and validationional data, improv
eriatric departmen
geriatric patientients in classic h
e/publication/repo
omain decision su
PA (with Mini-Men
ns decision suppoach patient of 75 ythe patient admittseen by the geriatt and the liaison teifferent multidiscipleast 1 to 2 VTE natrics
cing) , adapted at G-de
departments (dom vement of the distts (taking in accou
Chronic care
ts in classic hohospital (KCE-73
ort/financing-of-the
upport)
ntal State) but req
rt, appropriate woyears and older atted with a hip fractric nurse of the liaeam meets every plinary care teamsnurses. The comp
epartments, takin
main tailored delive
tribution of justifieunt the specificity
e
ospital 3-2008)
e-care-program-fo
uires extra staff
orkforce and tailort admission in hos
cture can be deteraison team week
s in the hospital position of the mul
g in account the
ery system design
ed days between gof the patients, th
or-geriatric-patient
ed delivery systemspital rmined as geriatric
ltidisciplinary team
specificity of eac
n)
geriatric departmehe treatment and
ts-in-classic-hosp
m design)
c
m can be determin
h patient, cost-eff
ents, more reasonthe needs) (doma
KCE Report 1
ital
ned by the institut
fective, easy cont
nable distribution oain quality process
192S
ion.
trol of
of the ses)
KCE Reports 19
2.10. QualitQuality develo
The full report cRecommendatiRole of the auth• major cond
tailored del• Need for de
account the• The solutio
phase wou(domain qu
• IT developm• Financial s
outcomes (• IT providersRole of the prof• A professio
initiatives a• The acade
developing Role of the prac• The introdu
formative a• The practic• The accura
92S
y developmentopment in genera
can be found on: hons horities: ditions to implemeivery system desiefinition of the stae potential negativon should take roold include the set
uality processes) ments for the datasupport or reallocdomain approprias should answer tfession: (domain aonal culture is thend to propose effimic and GP bodibalanced sets of
ctices and GPs uction of practice nd summative co
ces should have thate registration of d
t in general praal practice in Bel
https://kce.fgov.be
ent quality develogn and quality pro
akeholders’ role, ave consequences ot within the existting of a quality p
a collection and qucation of existing ate financing) to strict conditionsappropriate workf
e driving force for icient tools to impies have a definitindicators includi
based quality densequences of th
he necessary orgadata by the GPs i
actice in Belgiugium: status quo
e/publication/repo
opment in generaocesses) a time schedule fof both types of a
sting structures (foplatform with man
uality measuremebudgets is need
s that allow a dataforce) setting up quality
prove quality. te role to play tong clinical and no
evelopment is nee quality measureanization for perfos a condition to m
Chronic car
m: status quo o or quo vadis (K
ort/quality-develop
l practice: will of
for implementationassessment (domaor example the a
ny representative
ent should be discded to achieve a
a extraction from r
y initiatives in gen
teach the futureon clinical indicato
ecessary to fosterement (domain quorming quality devmeasure quality fro
e
or quo vadis?KCE-76-2008)
pment-in-general-p
f the authorities,
n, the balance beain tailored delive
accreditation bodiestakeholders in o
ussed within the Bsignificant impro
routinely collected
neral practice. The
e GPs about the crs
r quality improvemuality processes)velopment activitieom records routine
practice-in-belgium
a clear leadershi
etween summativeery system designes of the NIHDI o
order to look for sy
Be-Health Prograovement of the q
data (domain clin
e profession has
concepts of quali
ment in Belgium.
es (domain tailoreely collected (dom
m-status-quo-or-q
p and a national
e and formative a) of the Ministry of ynergy and devel
m (domain clinicauality of care in
nical information s
to participate in t
ity development a
The practices sh
d delivery systemmain clinical inform
quo-vadis
quality policy (do
ssessment, taking
f Public Health). Alop concrete prop
al information systterms of process
systems)
the definition of q
and are compete
hould be aware o
m design) mation systems)
61
omain
g into
A first posals
tems) s and
quality
nt for
of the
62
2.11. EffectsEffects of the M
The full report c
Recommendati
Improvements o
• Simplificatio• Taking into
persistency• Introduction• Need for re• Need for reNeed for linkingmicrosimulation
2.12. Qualit
Quality insura
The full report cRecommendati• Modification• Modification
variables • Coupling be• Re-evaluati• PROCARE
s of the MaximMaximum Billing
can be found on: h
ons:
of the maximum b
on of administrativo account the nuy of OOP-paymenn of an additional esearch specific onesearch on the covg the data on then model, in order t
y insurance for
nce for rectal ca
can be found on: hons on: n of some indicatons needed to im
etween BCR dataion of relevance a registration need
mum Billing systg system on heal
https://kce.fgov.be
billing system (dom
ve complexity (duumber of househts over time lower MAB-ceilingn the poorest houverage by the come health expenditto analyze cohere
r rectal cancer-
ncer-phase 2: de
https://kce.fgov.be
ors and PROCARprove the perform
abase and other aand interpretation d to be guaranteed
tem on health clth care consump
e/publication/repo
main appropriate f
e to expansion ofholds with more
g of 250euro for thuseholds mplimentary insuratures to the data ently future policy
-phase 2:devel
evelopment and
e/publication/repo
RE data/variables mance of data re
dministrative dataof indicators needd for international
Chronic care
care consumptption and financ
ort/effects-of-the-m
financing):
f the system) than 5% of OOP
he poorest house
ance on the revenues recommendations
lopment and te
testing of a set o
ort/quality-insuranc
necessary egistration: web a
abases is feasibleded in 2009 to selpopulation-based
e
tion and financial access to hea
maximum-billing-s
P-payments (esp
holds
(and the informas (domain approp
esting of a set o
of indicators (KC
ce-for-rectal-canc
application, simp
and reliable, coulect key-indicatorsd comparison
ial access to halth care (KCE-80
ystem-on-health-c
ecially chronically
ation on morbiditiriate financing)
of quality indica
CE-81-2008)
cer-phase-2-devel
lification of regist
pling with TC datas for implementati
ealth care 0-2008)
care-consumption
y ill and psychia
es). This kind of
ators
opment-and-testin
tration form, dec
abase is rather limion
KCE Report 1
n-and-financial-ac
atric patients) and
dataset will refin
ng-of-a-set-of-q
rease of number
mited
192S
d the
ne the
r of
KCE Reports 19
2.13. Long s
Long stay pati
The full report cRecommendatiRole and place • Need for de• Broader res• Two priority
and care tra• An integrat
patients witbeds
Trajectories of p• Need for deEquity • The develo• The policy oDatabases • Evaluation Future research• Need for co• Need for re• Need for re
92S
stay patients in
ents in psychiat
can be found on: hons: of T-beds in het p
ebate if long-term search needed to y key-points: do pajectories for patietive, scientific basth a chronic and s
patients (reorientaebate on the inter
pment of a care mof reorientation an
of validity and relih ontext-sensitive anesearch on the roleesearch on the var
n psychiatry T-b
ry T-beds (KCE-
https://kce.fgov.be
provision of servicstays in T-beds (determine if patie
persons with mentents who have a jsed vision neededsevere psychiatric
ation and reintegrpretation of deins
model needs to tand reintegration co
iability needed of
nalysis of social-ge and relevance oriability in medicat
beds
84-2008)
e/publication/repo
ces >6y) needs to be
ents with a long-tetal disabilities neeuridical statute?
d on the organizac disorder and the
ation) titutionalization: re
ke into account thould imply potenti
the MPG databas
geographical variaof social networkstion prescription a
Chronic car
ort/long-stay-patie
seen as a hospitaerm stay (>6y) neeed to be taken care
ational model in m development of a
eorientation in oth
he social protectioial equity problem
se
ability, taken into as and medication us
e
nts-in-psychiatry-t
al service ed to be taken care of in T-beds and
mental health carea balanced care m
her care services d
on and social justicms
account the agein
se
t-beds
re of in T-beds or d what are the mo
e with an identificmodel to optimize
differs from reinte
ce
g population
in alternative careost appropriate ca
cation of all types the transition of p
egration
e settings are services, supp
of care services patients out of the
63
port
for e T-
64
2.14. CompComparison o
The full report cRecommendati• on the shor• additional r• the basic lu• the social fa• the modifica• the savings
processes)• the evolutio
services (do• Programs n• Gradual ev
2.15. DiffereDifferentiated
The full report cRecommendati• The broade• The elemen
determinedthe impact
• Nurses nee• The differe
increase th• The differen
of the resul
parison of the cf the cost and th
can be found on: hons: rt term the currentesearch needed o
ump sums need toactors, which genation due to bias os may not lead t
on in determining omain appropriateneed to be set up olution towards ne
entiated practicpractice in nursi
can be found on: hons: (domain tailo
er delegation of lontary care, which
d: a clear descripton efficiency and
ed to be trained inntiation towards he attractiveness ontiation towards lots of efficiency an
cost and the quhe quality of two
https://kce.fgov.be
t manner of calculon the quality aspo be modified baseerates costs, neeof the denominatoto misplaced effe
the lump sums nee financing) for the evaluationew lump sums is
ce in nursing: oing: opportunitie
https://kce.fgov.beored delivery systegistic and adminisdemands basic c
tion of the functioquality of care. delegating taskshigher levels neeof the profession.ower and higher lend quality of care i
ality of two finafinancing system
e/publication/repo
lation can be mainpects (domain quaed on age and sod to be determineor must be maintaects. The reorga
eed to be go toge
n of the quality of cconsidered if thes
opportunities anes and limits (KC
e/publication/repoem design and apstrative tasks by locompetences, shon, an explicit des
, surveillance andeds to be elabora
evels need a refleis needed.
Chronic care
ancing systemsms of primary he
ort/comparison-of-
ntained (domain aality processes) ocio-economic stated (domain appropained and refined nization of savin
ether with monitori
care (domain quase new lump sums
nd limits CE-86-2008)
ort/differentiated-pppropriate workforocal hospital manould be delegatedcription of the rol
d to provide the neated in order to in
ection on preserva
e
s of primary heealth care in Belg
-the-cost-and-the-
appropriate financ
tus of the patientspriate financing) (domain appropriags must encoura
ing of the evolutio
ality processes) s strongly differ fro
practice-in-nursingrce) agement and autd to a caretaker (e, a competence
ecessary guidancencrease the caree
ation of the integra
ealth care in Begium (KCE-85-20
-quality-of-two-fina
cing)
s (domain appropr
ate financing) age accessibility,
on of the expendi
om the current am
g-opportunities-an
horities need to b(zorgkundige). Thprofile, training, t
e er perspectives o
ated care for the p
elgium 008)
ancing-systems-o
riate financing)
quality and effic
itures for patients
mounts (domain a
d-limits
e encouraged e role of this caretraining of nurses
f nurses with a m
patient. Pilot proje
KCE Report 1
f-primary-health
ciency (domain q
per lump sum an
ppropriate financi
e provider needs s and the monitor
masters degree a
ects and the monit
192S
quality
nd per
ing)
to be ing of
and to
toring
KCE Reports 19
2.16. ConsuConsumption
The full report cRecommendati• No justifica
systematic • An adapted
up rehabilitprofessiona
• Choice of rinformation
2.17. FatiguFatigue Syndro
The full report cRecommendatiBelgian referen• pilot project
centers (do• redistributio• structured c• early treatm
literature (d• more atten
decision su• No scientifi• Need for co• The therape
support)
92S
umption of physof physiotherapy
can be found on: hons:
ation for the distinchoice for K-nom
d nomenclature shtation treatment, oals (domain tailorerehabilitation sho on functional stat
ue Syndrome: dome: diagnosis,
can be found on: hons: ce centers did not of a more struct
omain tailored delion of the financingcare model must bment of CFS enhadomain decision stion must be give
upport) c evidence for theollection of data oneutic manuals wit
siotherapy andy and physical a
https://kce.fgov.be
nction between K-enclature in manyhould allow the aorientation of pated delivery systemuld only be basetus of rehabilitatio
diagnosis, treattreatment and o
https://kce.fgov.be
ot achieve to organured care model ivery system desig
g partly towards pbe based on scienances integration upport, quality proen to individual se
e combination of Cn the level of sevethin the care netw
d physical and nd rehabilitation
e/publication/repo
- and M- nomency hospitals has to ppropriate remunient to mono-or m
m design) ed on medical diaon patients availab
tment and orgaorganization of ca
e/publication/repo
nize a gradual carin which the primagn) hysiotherapists anntific methods in ointo society. The
ocesses) essions, next to g
CGT and GET, preerity of CFS (in a
works must be bas
Chronic car
rehabilitation mn medicine in Bel
ort/consumption-of
clature for the rehput to an end. (doeration of PRM smulti-disciplinary t
agnosis, functionable (domain decis
anization of carare (KCE-88-200
ort/fatigue-syndrom
re organization mary care plays an
nd psychologists (order to obtain val results of this ea
group sessions. B
eference must bepilot project) and sed on the manua
e
medicine in Bellgium (KCE-87-2
f-physiotherapy-a
abilitation of uncoomain appropriatepecialists for follotreatment, follow-
al status and patsion support)
re 8)
me-diagnosis-trea
odel, so financingimportant role, in
(domain approprialid data (for cost-early treatment nee
Both methods mu
e given to one of bregistration of com
als of which the ef
gium 008)
and-physical-and-r
omplicated casese financing) owing intellectual -up and coordinat
tient’s environmen
atment-and-organi
g should be restricn collaboration wit
ate financing) effectiveness) (doeds to be evaluat
ust be scientifical
both therapies (domorbidities (domaffectiveness is pro
rehabilitation-med
s following surgica
activities: medication of care provi
ntal situation. No
isation-of-care
cted: th the secondary c
main tailored delived and compared
ly compared for e
main decision supain clinical informaoven in clinical stu
dicine-in-belgium
al interventions. T
al diagnosis, drawded by allied hea
o uniformly collec
care and the refe
very system desigd with data in scie
effectiveness. (do
pport) ation systems) udies (domain dec
65
The
wing alth
ted
rence
gn) entific
omain
cision
66
• Need for indecision su
• Associated design)
• Need for tra
2.18. MakinMaking genera
The full report cRecommendatiInitiatives at the• The initial s• General pra• Accurate in• Specific GP• GP clerkshInitiatives to imp• Favoring th• Working in • The develo• Initiatives li• DevelopmeInitiatives to imp• The Belgian• Differences• Valid inform
formation towardsupport)
comorbidities no
aining of physioth
g general pracal practice attrac
can be found on: hons:
e level of medical selection of studenactice should be pnformation and lecP lectures on solutip of high quality sprove working con
he work in team orgroup practice pment of well orgke career breaks
ent of new career prove the financian authorities shous between incomemation about the G
s the care provide
ot studies in KCE
erapists and psyc
ctice attractive: ctive: encouragin
https://kce.fgov.be
faculties: (domainnts should target opositioned as a fuctures about this stions to overcomeshould be encouranditions: (domain r within networks
anized out-of-houfor a better balanperspectives
al conditions (domuld extend the cures of GPs and otheGP remuneration a
ers concerning the
E-report but need
chologists for the t
encouraging Gng GP attraction
e/publication/repo
n appropriate workon those with the lly-fledged specia
specialty in the cue difficulties that fuaged tailored delivery s
urs services ce with the private
main appropriate firent incentives forer specialists shoand diversification
Chronic care
e value of diagno
d for consensus a
treatment of CFS
GP attraction aand retention (K
ort/making-genera
kforce) best human quali
alty within medical rriculum uture GPs will enc
system design)
e life
nancing) r working in team uld be analyzed ton of payment mec
e
stic examinations
about their role in
(important role of
nd retention KCE-90-2008)
al-practice-attractiv
ities and profile thfaculties
counter on the fiel
and working in uno go towards a so
chanisms should b
s (specific workgro
n communal netw
f reference center
ve-encouraging-g
hat fists for GP spe
ld
nderserved areasoftening of these dbe given to studen
oup in Hoge Gezo
works (domain ta
rs) (domain appro
p-attraction-and-r
ecialty
differences nts
KCE Report 1
ondheidsraad) (do
ailored delivery sy
priate workforce)
retention
192S
omain
ystem
KCE Reports 19
2.19. FinancFinancing of th
The full report cRecommendatiData collection:• Since 2009• Need for se
information• Yearly follo• Study on th• Linking the Pilot project: • Decrease oFinancing of the• Need for re
providers, a
2.20. PharmPharmaceutica
The full report cdisease-a-rap RecommendatiClinical practice• Physicians
associated • Initiation of
patients Reimbursemen• Reimbursem
92S
cing of the gerihe geriatric day h
can be found on: hons: : domains health s
9 compulsory regisensibilization for t systems) w-up of the propo
he influence of durresults of the vali
or suspend financie pilot project: esearch on the galternative financin
maceutical and al and non-pharm
can be found on: h
ons on: e: should limit the with a significant
f ChEI treatment i
t: ment of Ginkgo bi
iatric day hosphospital (KCE-99
https://kce.fgov.be
system (financingstration of MKG inthe coding of char
ortion of diagnosisration of admissioidation, based on
ing of hospitals w
goals of GDZ, finang methods, mini
non-pharmacemaceutical interv
https://kce.fgov.be
use of antipsychincrease in mortan hospitalized me
iloba cannot be ju
ital 9-2008)
e/publication/repo
) and clinical inforn a GDH (domain racteristics, the co
s , therapy and rehon on the financing
MKG of 2004, 20
ith a significant lo
ancial needs, satmal norm for finan
eutical intervenventions for Alzh
e/publication/repo
otics in AD patieality. edically instable A
ustified
Chronic car
ort/financing-of-the
rmation systemsclinical informatioo morbidities and
habilitation in the g, using the MKG 005 and 2006 to th
ower occupancy ra
tisfaction of patiencing (domain app
ntions for Alzheheimer’s Disease
ort/pharmaceutical
nts to situations
AD patients should
e
e-geriatric-day-hos
on systems) the contacts with
total number of adata of 2004, 200
he registrations st
ate (domain tailore
nts, relatives andpropriate financing
eimer’s Diseasee, a rapid assess
l-and-non-pharma
where their use
d be judged caref
spital
h the health servic
activities (domain 05 and 2006 (domtarting from 2009
ed delivery system
d care providers, g)
e, a rapid assement (KCE-111-2
aceutical-intervent
is absolutely nec
fully given the slig
ces of geriatric pa
quality processesmain quality proce(domain quality p
m design)
cost for the patie
ssment 2010)
tions-for-alzheime
cessary. The use
ghtly increased ea
atients (domain c
s) sses) rocesses)
ent, role of other
er%E2%80%99s-
of antipsychotics
arly mortality in su
67
linical
r care
s is
uch
68
• The reimbu• Reimbursem
December • During revis• The non-phMethodological• Health tech• Coding of n
2.21. OrganOrganization o
The full report cRecommendatiDefinition of pa• patients sho
whatever th• this “palliat
initially perf• the meanin
when feasib• this definitio
is specific f• ImportanceTraining of hea• courses in
education b• the content
problems, sOrganization of
ursement of memament of ChEIs ca21,2001 sion procedures, tharmaceutical inte recommendation
hnology assessmenon-reimbursed pr
nization of palliaof palliative care
can be found on: hons: lliative patients: (dould be recognizeheir life expectancive status” is diffeformed and followg of “needs” shouble and preferred on of a patient whfor each health cae to identify all palllth care professiopalliative care (“
by scientific societt of this basic trainspiritual needs; f palliative care: (d
antine in monothean be continued
the possible beneervention should bns: ents should includrescription medici
ative care in Bein Belgium (KCE
https://kce.fgov.be
domains tailored ded as “palliative pcy; erent from the “te
wed at regular inteuld consider all diby the patient;
ho needs palliativere system and thaliative patients, innals: (domain app“basic training”) sties; ning should encom
domain tailored de
erapy should be qubut should be su
efits on behaviourabe implemented in
de as much as posnes is necessary
elgium E-115-2009)
e/publication/repo
delivery system depatients” when the
erminal stage” of rvals by the main mensions, includi
e care should be at requires a conscluding non-oncopropriate workforcshould be include
mpass common m
elivery system des
Chronic care
uestioned given thbject of a revisio
al disturbances inn Belgium, ideally
ssible all sources for analyzing thei
ort/organisation-of
esign) ey are in an advan
a disease and inphysician in collang the need for in
different from thesensus at the levelogical patients: p
ce) ed in the curriculu
major subjects acro
sign)
e
he very weak clinion of reimburseme
n geriatric patientsas a large random
of evidence and nir use
f-palliative-care-in
nced or terminal s
cludes the needsaboration with a panformation and fo
e definition that givel of the Belgian hepatients with adva
um of all health
oss all curricula e
ical efficacy and laent criteria as for
s needs to be takemized trial
not only trials pub
-belgium
stage of severe, p
s assessment of talliative care teamr social support in
ves access to finaealth care systemnced chronic cond
professionals and
e.g., the control of
ack of robust costreseen under arti
en into account
blished
progressive and li
the patient. This am; n order to allow pa
ancial or social sum.
ditions, patients w
d should also be
symptoms, comm
KCE Report 1
t-effectiveness dacle 38 of the law
ife threatening dis
assessment shou
atients to stay at
upport, a definition
with dementia
offered as conti
munication skills, s
192S
ata w of
sease
uld be
home
n that
nuing
social
KCE Reports 19
• the care mo• relatives ar
home when• need for a r• standardizeRegistration: (d• is required • this data co
indicators.Cost: (domain a• need for en
the better b
2.22. Use oUse of point-o
The full report cRecommendatiOrganization: • Organizatio
manageme• Many data • Pilot study
self-testing Aspects need to• Selection o• Training of
test may be• Assistance • An external
92S
odel should be mure a target group n they expressed treinforcement of led records are reqomain clinical infofor all settings thaollection should b
appropriate financncouragement of balance between t
f point-of-care f-care devices in
can be found on: hons:
on of long term oent) currently unavailato calculate real c(domain appropri
o be taken into acf patients based othe patient comp
e less demanding and follow-up shol quality control of
ultidisciplinary andto be included inthis preference; inks between settquired in all settingormation systemsat benefit from a sbe standardized a
cing) intervention of pathis care model an
devices in patin patients with or
https://kce.fgov.be
oral anticoagulan
able in Belgium, ecosts and assess iate financing) ccount: on personal willingpulsory and standin case of patient
ould be available f the POC devices
d tailored to the inn the care models
tings to offer a congs to register and)
specific financing fand include data
alliative care mobind the patient’s ne
ients with oral aral anticoagulati
e/publication/repo
nt therapy monito
conomic conclusifinancial impact: d
gness and abilitiesdardized. If the pat selftesting and wfor solving proble
s is needed. (dom
Chronic car
ndividual patient s in home settings
ntinuity of care to to follow advance
for caring for palliaon the number o
ile teams in hospeed
anticoagulationon: a health tech
ort/use-of-point-of-
oring: patients se
ons based on hypdefine number an
s + close relativesatient passes the will focus on the abems with the testinmain quality proces
e
s in order to prev
the patient; e care planning an
ative patients, incof patients, their
itals in the light o
n: a health techhnology assessm
-care-devices-in-p
elf management
pothetical scenariond characteristics
s may also be selepractical test, a cbility to perform thng or the adaptatiosses)
vent their exhaust
nd preferred place
cluding the nursingprofile, the proce
of the lower costs
hnology assessment (KCE-117-2
patients-with-oral-
and to a less e
os (domain tailoreof patients eligible
ected (domain secertification is obtahe test. (domain son of the doses (d
tion and to allow
e of death
g homes; ess of care and w
(in comparison w
sment 009)
anticoagulation-a
xtent patient self
ed delivery systeme for patient self-m
lf-management) ained for patient self-management)
domain self-manag
the patients to st
when available, q
with classical care
-health-techn
f testing (domain
m design) management or p
self-management
gement)
69
tay at
quality
e) and
n self-
atient
. This
70
Cost: • cost items t
appropriatePOC devices: • For the use
decision su• Regardless
monitoring Evaluation An evaluation otreatment. (dom
2.23. AdvanAdvantages, d
The full report quality%E2%80Recommendati• Quality can• Everybody • The implem• Accurate, v• A monitor s
2.24. FinancFinancing of h
The full report cRecommendati• A profound
vision on he
to be considered e financing)
e of POC devicesupport) s of the use of Pare essential. (do
of these recommmains decision sup
ntages, disadvadisadvantages an
can be found o0%99 ons: (domain qua
n be measured by who achieve the
mentation of pay fovalidated and alreasystem must be pr
cing of home nhome nursing in
can be found on: hons: (domain tailo political reflectionealth services pro
for reimbursemen
s by a GP or in a
POC devices, the omain decision su
endations is neepport and clinical
antages and fend feasibility of t
on: https://kce.fgo
ality processes) structure, procesquality targets neor quality-programady available datarovided from the s
nursing in BelgiBelgium (KCE-12
https://kce.fgov.beored delivery systen is needed on thovision. One of the
nt: patient training
an anticoagulatio
development of pport)
ded when new ainformation syste
easibility of the he introduction o
ov.be/publication/r
ss as intermediateed to be rewarded
ms has to be donea are preferred. Tstart
um 22-2010)
e/publication/repoem design) e respective rolese future challenge
Chronic care
, the POC device
n clinic, the evide
guidelines and tr
anticoagulants becms)
introduction of of ‘Pay for Quali
report/advantages
e outcome indicatod. The incentive s
e gradually and wihis implies an inve
ort/financing-of-ho
s of different healtes will be to asses
e
, strips and qualit
ence is not suffic
raining of health
come a standard
f ‘Pay for Qualitty’ programmes
s-disadvantages-a
ors should be targetedth pilot programsestment in IT dev
me-nursing-in-be
th services functioss to what extent t
ty control, and adv
ciently robust to r
professionals inv
of care for patie
ty’ programmein Belgium (KCE
and-feasibility-of-t
d at all providers,
velopment and an
lgium
ons and on how ththe developments
vice from a health
recommend its us
volved in oral ant
ents with long ter
s in Belgium E-118-2009)
he-introduction-of
at individual and o
audit system
hese functions cos in tele-monitoring
KCE Report 1
h professional. (do
se at present. (do
ticoagulation treat
rm oral anticoagu
f-%E2%80%98pa
organizational lev
onnect within an og, patient support
192S
omain
omain
tment
lation
ay-for-
vel
overall t tools
KCE Reports 19
and indepestructured n
• A mixed fassessmen
• A clearer dbe financednursing ( tonursing sec
• Long-term complexity Technical o
• Little is curneeds to geCost calculservices of
• Part of the data-collectassessmen
• In terms of should be tto be integrhome nursievaluated g
Further methodsystem design)Organization an
92S
endent living technegotiations betwfinancing systemnt)(lump sum finanistinction should bd via a parallel hoo mobilise the necctor (the subcontracare payment neand overlap in fin
or specialised carerrently known on tet form on the coations should takethe different typefinancing can betion is needed in
nt of usability of difquality of care, it
taken into accounrated in the reflecng with a part-tim
given the concerndological reflection nd financing of ch
hnologies will affeeen the different p
m in home nursincing for chronic cbe made betweenospital financing scessary skills for sacting of specialiseeds to more clenancing rules. Paye should be basedthe cost structurellection of data toe into account thes of home nursing based on depen
n a Belgian homefferent dependenchas to be conside
nt. If they are paidction on overall heme job as self-emp
s with regard to thns are needed on
ronic dialysis in B
ect on how nurspolitical levels. ng is probably
care) (domain appn post-acute care system (DRG or cspecialised nursinsed post acute cararly disentangle
yment for chronic d on a fee-for serve of home nursingo document thesee organizational cg providers (large ndency categoriese nursing context cy scales in the dered to what exte
d differently, a discealth care provisioployed nurse perfohe continuity and how “pay for per
Belgium
Chronic car
sing care and su
the most acceppropriate financing
and long term cacase-mix). A furthng care). One shore to home nurse basic care and foconditions shouldvice payment systg. It is recommene real costs, as cucharacteristics of t
organizations, ses or resource utiliz
performing a coaily practice of hont characteristics cussion will be neon and quality of corming only speciquality of care frorformance” or “pay
e
pport can be org
ptable and approg) are: It could be disher reflection is neould also reflect onproviders, accordollow-up of chron
d be based on an tem with adequateded to study to w
urrently no standathe providers, e.gelf-employed nursezation groups, whomparative validatome nursing.
of the nurses suceeded on the critecare. Within this loalized nursing int
om an integrated cy for quality” can
ganised and finan
opriate financing
scussed whether eeded on the coln how to employ
ding to the quality nic conditions froevaluation of patiee tariffs
what extent fees/tardised data are a. the different logies) and the region
hich need to be btion (reliability an
ch as their qualificeria used to justifyogic, the practice erventions to pati
care perspective. be introduced in
nced. This gener
g system in Bel
some specific polaboration betweesufficiently qualifistandards of the m technical care ent dependency f
ariffs cover real cavailable for all hoistic structure andnal characteristicsetter defined. A f
nd validity) of inst
cation, level of expy different paymenof nurses combinents at home (che
home nursing. (do
ral debate will re
gium (+ continu
ost-acute care canen hospitals and ed nurses in the hospitals). to handle the cu
for lump sum finan
costs. A further deome nursing provd the so-called bas (urban/rural). ield study with prtruments, includin
pertise and expernts. This debate nning a main job ouerry picking) shou
omain tailored de
71
equire
uously
n also home home
urrent ncing.
ebate iders. ck-up
rimary ng an
rience needs utside uld be
elivery
72
2.25. FinancOrganization a
The full report cRecommendatiGuidelines: (do• DevelopmeCounseling: (do• Every patie• Could be in• Inclusion ofFinancing: (dom• Reimbursem
compensat• Coverage o• The financi
the other ha• A payment
should be clink with thmechanism
• The reimbutransportati
It should be inv
cing of home nand financing of
can be found on: hons: main decision sup
ent of clinical guideomain self-managent informed timelyncluded as a requif tool to assess efmains appropriatement of dialysis ion for underfinanof intellectual act ong through a lumand should be recper hospital HD
considered. A corre historical per d
ms for dialysis, be ursement of transpion to patients. If aestigated why and
nursing in Belgichronic dialysis
https://kce.fgov.be
pport) elines to improve
gement) y, fully and objectirement for all preffect of introducing financing) treatments shoul
nced hospital servof nephrologists a
mp sum and a medconsidered. session, per sate
rection for co-moriem price and theabandoned. portation to and fa private transpord to what extent th
um in Belgium (KCE
e/publication/repo
decision making
ively about differee-dialysis patients g counseling serv
d reflect real cosvices and consumables dical fee for hosp
ellite HD session rbidities that are ce system of lump
rom the dialysis crtation means is she amounts paid t
Chronic care
E-124-2010)
ort/organisation-an
including patient p
ent dialysis modalin ambulatory carices in dialysis ce
sts to hospital an
by one fee for serital HD on the on
and per PD weeclearly correlated wp sum bonuses fo
centre with privatehared by patientsto home nursing s
e
nd-financing-of-ch
participation
ities re pathway for ES
enters in data regis
n patient and dial
rvice for hospital He hand and throu
ek that resembleswith the costs of t
or hospital HD ca
e means should b the reimbursemeservices differ bet
hronic-dialysis-in-b
SRD stration protocols
lysis reimbursem
HD should be abaugh a lump sum o
s more closely thethe ambulatory dian, in the context
be reconsidered inent should only between hospitals (d
belgium
of Belgian associ
ent should not b
andoned only for alternative
e real costs of eaalysis treatment cof a complete re
n order to better re charged to the Ndomain tailored de
KCE Report 1
iation for nephrolo
e justified on bas
e dialysis modalitie
ach treatment mocan be consideredevision of the fina
reflect the real coNIHDI once. elivery system des
192S
ogy
sis of
es on
odality d. The ancing
sts of
sign)
KCE Reports 19
2.26. The reThe reference
The full report cRecommendatiDifferent measu• Prescribers
INN prescri• Pharmacist• Patients: inStructure of theReference price
2.27. A first A first step tow
The full report cRecommendati• The constru• Clear objec• Reports ne
health data• First priority• For the eva
disease doindicators a
• The scope • The selectio• In the selec
consulted fo• The absolu
92S
eference price price system an
can be found on: hons: ure to reduce amos: a targeted increiption (domain tailts: allow substituticrease patient’s a
e system: e: setting referenc
step towards mwards measuring
can be found on: hons: (domain quauction of a complectives needs to beed to be produce. A yearly report iy is to determine taluation of the heamains, specific w
and the use of appof the performancon of indicators nection of indicatorsor the creation of te precondition fo
system and sond socioeconomi
https://kce.fgov.be
ount of reference ease of low cost lored delivery syson right (domain t
awareness of refe
ce price with respe
measuring the g the performanc
https://kce.fgov.beality processes) ete set of indicatoe determined and d on a regular bas feasible if sufficthe gaps in the cualth care system
working groups shpropriate data. Thce system should eed to be specifie a balance need tthese new indicat
or a performance s
ocioeconomic dic differences in
e/publication/repo
supplements: prescription quotatem design) tailored delivery srence supplemen
ect to price of all l
performance oce of the Belgian
e/publication/repo
rs must be planneindicators need to
asis, taking into accient staff is providurrent report all performance dould be set up toe involvement of not only focus on
ed on the Belgian to be found betwetors. This will demsystem is the invo
Chronic car
differences in ththe use of low c
ort/the-reference-p
a in consultation
system design) nt (clear informatio
ow cist drugs with
of the Belgian hn healthcare syst
ort/a-first-step-tow
ed and consolidato searched to evaccount the data deded.
dimensions need o guarantee the copatient organizati
n health care but ahealth care policyeen the already in
mand a close collaolvement and colla
e
he use of low cost drugs (KCE-
price-system-and-
with the National
on on amount and
hin a cluster (dom
healthcare systtem (KCE-128-20
ards-measuring-t
ted. The required aluate these objecemands by intern
to be consideredonsultation of releons in the stakeho
also comprise othey ncluded indicatorsaboration with the aboration of all he
cost drugs 126-2010)
-socioeconomic-d
Commission Phy
d type of suppleme
main tailored delive
tem 010)
he-performance-o
staff needs to be ctives ational organizati
. For some dimenevant indicator soolder group coulder aspects, like no
s and the new inddata managers.
ealth authorities.
ifferences-in-the-u
ysicians-Sickness
ent paid) (domain
ery system design
of-the-belgian-hea
provided
ons and the perio
nsions, domains oources, the correcd correct the gap.on-medical determ
icators. Available
use-of-low-cost-d
s Funds + Stimula
self-managemen
n)
althcare-system
odicity of some Be
of the health systect definition of sel
minants of health
databases need
73
ate of
nt)
elgian
em or ected
to be
74
• The workinboard, whic
• A political w• The interpre
need to be • Data suppli• Each data s• The availab• The results• The results• For the cor
public servi• Performanc
2.28. SeamSeamless care
The full report cRecommendati• A need to
results of th• Attention of
responsibili• The sharing
clinical info• Seamless c• The trainingThe possible finaimed at demon
g group, responsch represents all rwork group need tetation of the perftaken into accouniers need to be invsupplier need to inbility of data need need to be calcu of this report are rrect use and inteice need to play ace indicators have
less care for me (KCE-131-2010)
can be found on: hons: compile, publish
his research (domf care providers aity of all (domainsg of patient data rmation systems) care focusing on mg of health professnancing of initiativnstrating subsequ
ible for the selectrelevant competento be set up by theformance measurnt volved in the procndicate a single pto be improved lated on a nationapreliminary
erpretation of this a pro-active role ine a warning functio
medications )
https://kce.fgov.be
and circulate goomain decision suppand patients shous tailored delivery
in electronic form
medications at adsionals in ambulaves relating to seauent clinical and p
ion, measuremennces. e Interministerial crement demands m
cess of indicator dperson of contact t
al level, if necessa
and future reporn the communication. The responsib
e/publication/repo
od practice guideport) uld be drawn to tsystem design anm should become
mission and dischatory care or in hosamless care focusossibly economic
Chronic care
nt and reporting of
conference to evamore than only da
definition and meato facilitate data tr
ary more detailed
rts, a communication and use of theble services and o
ort/seamless-care-
elines on seamles
the importance ond self-managemee increasingly op
harge should be fospitals should incsing on medicatio
c effects (domain t
e
f the performance
aluate the use of tata on health care
asurement ransmission
results can be ca
tion and distributie report organizations need
-with-regard-to-me
ss care with rega
f the continuity ofent) perational, with re
ormalized in clearlude aspects relat
ons between homtailored delivery s
e indicators, need
he report e, other factors like
alculated
ion plan needs to
d to be identified t
edications-betwee
ard to medication,
f medications at t
espect to the rule
r procedures (domting to this issue (e and hospital shystem design)
to be guided by a
e context and non
o be set up. The
to put action point
en-hospital-and-h
, based on intern
the time of transi
es of safety and c
main decision supp(domains approprhould be subject to
KCE Report 1
a scientific consul
n-medical determi
NIHDI and the fe
ts into action
ome
national guidelines
tion and to the sh
confidentiality (do
port) iate workforce) o a credible evalu
192S
ltancy
nants
ederal
s and
hared
omain
uation
KCE Reports 19
2.29. EmergEmergency ps
The full report cRecommendatiGeneral • Urgent psy
necessary i• Coordinatio
function fits• Loco-region• Comprehen
model) andlist of suppemergent pemergency
Geographical d• One SEPH• A buffer be
done by poRegistration an• Need for re• Need for fo
2.30. The BThe Belgian he
The full report cRecommendati• Further imp
the overall
92S
gency psychiatsychiatric care fo
can be found on: hons on:
chiatric care (SEPin residential careon of activities ans: structural entity nal level: expansionsive approach ind collaboration for ortive aids (mobil
psychiatric care ney department in hoistribution and aid-function per 150
ed capacity needsoling. d research
esearch on the neellow-up evaluation
Belgian health sealth system in 2
can be found on: hons: (domain tailo
provement in effecsystem
tric care for chior children and a
https://kce.fgov.be
PH) needs to be de, the developmennd financing needcovering the straton and financing o
n mental health caactivities on indive outreach teamseeds to be focuseospital ds 000 minors and a
s to be foreseen f
eds of mental hean focused on the o
system in 20102010 (KCE-138-2
https://kce.fgov.beored delivery systectiveness of prev
ldren and adoldolescents (KCE
e/publication/repo
developed as a funt of this function nded between fedtegic and policy aof collaboration mare: clear distinctiovidual patient leves, telephonic served on ambulatory
at least one per prfor urgent care. T
alth care for childroutcomes on patie
0 010)
e/publication/repoem design) entive care, appro
Chronic car
escents E-135-2010)
ort/emergency-psy
unction and not aneeds to fit in the eral level, comm
aspects to realize tmodels between di
on needed betweel; guarantee of dvices, consultationy care in the envir
rovince, resulting The guarantee of
ren and adolescenent level and on t
ort/the-belgian-hea
opriateness of ca
e
ychiatric-care-for-c
s a fixed organizaorganization of m
munities and regiothe organizationafferent types of ca
een collaboration birect and accessib
n room, observatioronment of the ch
in 15 psychiatric ea maximum wait
nts, combined withhe effectiveness a
alth-system-in-201
are, efficiency and
children-and-adol
ational structure: mental health careons to develop a l adaptations in maregivers between partneroble care in SEPHon units, normal aild or adolescent;
emergency care ftime with a minim
h a further develoand efficiency of t
10
d sustainability co
escents
in priority ambula for children and aconceptual fram
mental health care
organizations and-function; the SEPand strong secure linkage between
functions mum of backup be
opment of data regthe collaboration m
uld further enhan
atory care and onladolescents
mework in which t
caregivers (netwPH-function needed residential bed
n SEPH-function a
ed capacity must
gistration models
nce the performan
75
y if
the
ork s a
ds); and
be
nce of
76
• Future chan
2.31. CardiaCardiac rehab
The full report cRecommendatiGood clinical pr• Any cardiac
should be asessions to
• Exercise an• Raising GP• GP and car• Lifelong follHealth insurancBilling codes frehabilitation se
2.32. OrganOrganization o
The full report cRecommendati• In the balan• This will on
integration • The authori• Non-reside• Intensive m
instance ba
nges and reforms
ac rehabilitationilitation: clinical
can be found on: hons: ractice: (domain dc patient who hasallowed to benefit o improve cardiovand other rehabilitaP’ awareness and rdiologists should low-up by GP necce management: (for cardiac rehabessions with phys
nization of menof mental health
can be found on: hons on: nced care model, ly be possible witinto society possiities must continuntial care and sup
multidisciplinary suased on the ACT m
s will aim at simplif
n: clinical effeceffectiveness an
https://kce.fgov.be
decision support)s undergone a cofrom: medical che
ascular risk profileation sessions spreducation in relatraise the patients
cessary to mainta(domains tailored bilitation should iotherapist and th
tal health carecare for persons
https://kce.fgov.be
further deinstitutioth the simultaneouble and based one with the elabora
pport needs to be upport and coordinmodel
fying the system i
ctiveness and und utilization in B
e/publication/repo
oronary interventieckup, exercise pe (could be in ambread over several tion to importances’ awareness of thin healthy lifestyledelivery system dmake a distinctie sessions with o
for persons ws with severe and
e/publication/repo
onalization for perus development on the individual neation of a mix of pdeveloped. Spec
nation of care for
Chronic care
n order to make it
utilization in BeBelgium (KCE-14
ort/cardiac-rehabil
ion of who has bprogram (with advibulatory care) months (to ensure
e of exercise he importance of ee changes design) on between actuther health profes
ith severe and d persistent men
ort/organization-of
rsons suffering froof adapted care aneds of each patie
protected housing ial attention is neepeople suffering f
e
t more homogene
elgium 40-2010)
itation-clinical-effe
een discharged aice of specialist in
e lifestyle change
exercise
ual multidisciplinassionals
persistent menntal illness. What
f-mental-health-ca
om severe and pend housing in the nt with different optieded to support dfrom a SPMI who
eous
ectiveness-and-ut
after hospitalization cardiac rehabilita
es)
ary assessment
ntal illness. Wht is the evidence
are-for-persons-wi
ersistent mental illpersonal environm
ons in autonomy aily activities andare frequently re-
tilisation-in-belgium
on for coronary dation), limited num
by specialist in
hat is the evide? (KCE-144-2010
ith-severe-and-pe
ness is recommenment of the patien
and intensity of s reintegration into-hospitalized mus
KCE Report 1
m
disease or heart fmber of compleme
cardiac rehabilit
nce? 0)
ersistent-mental-
nded nts, making optim
upport o working life t be encouraged,
192S
failure entary
tation,
um
for
KCE Reports 19
• The financi• Further dev
available da• Intermediat• It is absolu
integrated c• The propos
2.33. MentaMental health c
The full report cprojects%E2%8Recommendati• Stimulation• For implem
a permanen• In the deve• Within the f• On the lev
agreements• The role of • The conditi
patient • The involve• More under• Need for th• Need for su• Innovative
modalities b
92S
al aspect must novelopment of theata, it is not possite critical evaluatioutely necessary tcare or continuity sed development o
al health care recare reforms: ev
can be found on: h80%99 ons on: of the organizatio
mentation of structunt interministerial lopment of policy framework of a geel of collaboratios the coordinator monal financing of
ement of primary crstanding is needee development of
ufficient preparatioprojects on interobut also on impac
ot prevent any pate current care strble to predict whicons are needed, bto describe explicof care, in order tof health care req
eforms: evaluavaluation researc
https://kce.fgov.be
onal innovation inural programs, a cdepartment. programs, more a
eneral common poon, more attention
must be defined asinterprofessional
care is a necessityed in the manner f a mutual framewon and guidance iorganizational andct on societal parti
tient from evolvingructures must be ch forms of care aboth on level of cacitly in policy papto avoid the samequires the necessa
ation research och of “therapeuti
e/publication/repo
mental health cacontinuous fine-tu
attention should bolicy, separate sun should be give
s a function who sconsultation mus
y in a de-institutiohow to involve pa
work for the develon terms of respecd interprofessionacipation and wellb
Chronic car
g towards the moscarried out syst
and how many plaare process as onpers or discussioe term being used ary coordination b
of “therapeutic c projects” (KCE
ort/mental-health-c
re by the governmuning between diff
be given to commbprograms need tn to the concrete
stimulates and supst be maintained
onalized care modatient and relativesopment of a adaptct for duty of profeal collaboration nbeing of the patien
e
st appropriate formtematically and inaces will be necesn level of the patieons what is mean
very different orgbetween federal an
projects” E-146-2010)
care-reforms-eval
ment via structuraferent policy autho
unication with andto be developed foe elaboration of t
pports the collabobut refined by inc
del s on an efficient wted care plan in m
essional confidenteed to be continunt
m of care n stages. Based ssary. nt. Australia could
nt by care circuitanizational concend regional policy
uation-research-o
l strategic programorities is needed.
d support to the exor age-specific tathe configuration
oration and not oncreasing the cons
way during the intemental health careiality within the theuous evaluated, n
on current scien
d be used as a mos, care networks
epts. y levels.
of-%E2%80%98th
ms This process sho
xecuting sector rget groups or speof the collaborat
nly as an administrsultation on the ev
erprofessional con erapeutic teams not only on policy
tific knowledge a
odel s, care coordinati
herapeutic-
ould be supported
ecific domains tion and the mut
rative support. volving needs of t
nsultation
y and organizatio
77
and
on,
by
tual
the
nal
78
• Need for im
2.34. QualitQuality indicat
The full report cRecommendatiQuality of care:• Follow-up oImplementation• Need for ris• Appropriate• Revision of• Nomenclatu• Correct use• Adding “recAdding to the M
2.35. QualitQuality indicat
The full report cRecommendatiImplementation• Modification• Cancer reg• use of 7th e• delay betwe• availability
mplementation of p
y indicators in tors in oncology
can be found on: hons: (domain quality p
of quality of care sn of QI set: (domask-adjustment shoe cut-off values def existing nomenclure codes for CT e of 7th edition of Tcurrence” to curreMDT form of radiat
y indicators in tors in oncology
can be found on: hons:
n of quality indicatons of nomenclaturistration: d TNM classificateen incidence yeaof national data o
prospective regist
oncology: testiy: testis cancer (K
https://kce.fgov.be
processes) should be consideins quality procesould be thoroughlyefined for each QIlature codes for teand MRI need to TNM classificationnt list of variablestion dose and field
oncology: breay: breast cancer (
https://kce.fgov.be
or set: Data-relatere (codes for CT,
tion and registratioar and availability
on causes of morta
ration of patient d
is cancer KCE-149-2010)
e/publication/repo
ered (most appropsses and clinical iny assessed in collaboration westicular surgery tbe specific to an a
n and its registratis with mandatory rd (clinical target v
ast cancer (KCE-150-2010)
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ed actions (domaiMRI, percutaneou
on of cTNM and pof data at 2 years
ality and linkages
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data and exploit th
ort/quality-indicato
priate method neenformation system
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volume), inclusion
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ins quality procesus biopsy and cyto
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ncology e standards n
cancer registry in clinical trial
ors-in-oncology-bre
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stration data withi
ntific evaluations
stis-cancer
ned)
east-cancer
nformation systement specific to ana
n delay of 2 years
ms) atomic location)
s (according to Eu
KCE Report 1
uropean regulation
192S
n)
KCE Reports 19
• adding of vpositive lym
• standardiza• regular pros
2.36. PharmPharmacologic
The full report cRecommendatiFor clinicians: • The pharma• The individu• All patients
more effect• In the abse
on the defintreatment isnormal rangrisk is low,
• Consideratiexpected fr
• The pharmamendable
• Monitoring For policy make• The utilizat
more risk fatreat algorit
• The health • Expensive
92S
variables to list ofmph nodes, resectation of breast patspective surveys
macological precal prevention of
can be found on: hons on:
acological prevenual fracture risk is
s presenting a fragtive on vertebral fr
ence of prior fragilinition of what a hs recommended ge, a treatment isa treatment is notions, such as patrom treatment, an
macological preve to non-pharmacotreatment with repers: ion of clinical algoactors, particularlythm for individualsservices should bmolecules which
f variables for mation margins after thology report reqon selected topics
evention of fragf fragility fractur
https://kce.fgov.be
ntion of fragility fras assessed with clgility fracture shoractures than on fity fractures, a str
high 10-year fractbut only protectivs not recommendt recommended tient preferences d risk of serious antion should be ological interventiopeated DXA is no
orithms for assessy during consultas at high-risk woulbe encouraged to clinical benefit is
andatory registratisurgery, radiationuired s (random sample
gility fractures ires in Belgium (K
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actures should be linical algorithms. uld be proposed fractures at other rategy based on thure risk is. Follow
ve effect of pharmed (this does not
or adherence, shadverse events shviewed as a comons. Causes of se
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sing the absoluteations in general mld be an asset. consider treatmenot supported by
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on at cancer regn dose and field
e of medical files)
n Belgium KCE-159-2011)
ort/pharmacologica
targeted to high-rBMD should be ma pharmacologicasites. NNT for prehe individual absowing treatment strmacological treatm
preclude clinician
hould also intervehould be discussemponent of a comecondary osteopoand currently not e
10-year risk of frmedicine. It shoul
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al-prevention-of-fr
risk patients, i.e. pmeasured only in al prevention of fueventing I hip fractolute risk of fracturategy is recommment on vertebral ns from consideri
ene in the treatmd with the patientmprehensive manrosis should also enough evidence
ragility fractures sld be part of the G
t presenting a fragould not be reimbu
stant recurrence,
ragility-fractures-in
patients who will bindividuals presenurther fractures. Wture is high. re must be implemended: if 10-yearfractures; if 10-y
ng a treatment on
ent decision. Abs. nagement plan, wbe duly identifiedto recommend ot
should be promoteGlobal Medical Fi
gility fracture, e.g.ursed except for v
recruitment in cl
n-belgium
benefit the most frnting risk factors oWorth mentioning
mented. There is r fracture risk is hyear fracture risk n individual basis
solute risk of frac
which identifies p and treated. her types of treatm
ed in all individuaile. The dissemina
. by an informationvery specific indica
inical trials, numb
rom the treatment of fragility fractureg, such prevention
today no consenshigh with low BMDis high with BMD
s); if 10-year fractu
ctures, risk reduct
primarily risk fact
ment monitoring
als presenting oneation of screen-a
n campaign ations
79
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es n is
sus D a D in ure
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ors
e or nd-
80
2.37. DemeDementia: whi
The full report cRecommendatiCategories of in• Support an
effect on in• Training for• Physical ac• Cognitive sNo details on im• Tailored to • Followed up• Continued oThe data curren
2.38. DiagnDiagnosis and
The full report cRecommendati• Doppler ult
limbs • Thermal ab
comparable• An adjustm
local anaes• Registration
regards the
entia: which nonch non-pharmac
can be found on: hons on:
nterventions nd training for infostitutionalization r residential care sctivity programs attimulation/training
mplementation butpatients and theirp by specially traiover time, with regntly available for o
osis and treatmd treatment of va
can be found on: hons on: trasound is the di
blation techniquese in the medium te
ment of the list of bsthesia (or even wn of serious compe use of foam scle
n-pharmacologcological interve
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ormal caregivers,
staff t home or in residg therapy t evidence that thr close informal caned staff gular contacts in oother non-pharma
ment of varicosricose veins in th
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agnostic techniqu
s (laser, radiofreqerm and the technbilling acts is requ
without anaesthesiplications and relaerotherapy)
gical interventiontions? (KCE-16
e/publication/repo
including multico
ential facilities
ey should be arers to meet their
order to produce scological interven
se veins in the he legs (KCE-164
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ue that is currentl
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Chronic care
ons 60-2011)
ort/dementiawhich
omponent interven
r needs as closely
significant effectsntions do not allow
legs 4-2011)
ort/diagnosis-and-t
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otherapy may be rried out under locese new techniqupy) for the treatmeto verify the long
e
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w recommendation
treatment-of-varic
to steer therapeu
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gical-interventions
his has been sho
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s alternatives for or even without anromotes their useins without compleffectiveness of t
s
own to have amo
legs
elation to varicos
conventional surgnaesthesia for scle in an outpatientsications these new techniq
KCE Report 1
ng others a posit
e veins of the low
gery: the results aerotherapy s environment und
ques (particularly
192S
tive
wer
are
der
as
KCE Reports 19
• The current• Medication
2.39. EntitleEntitlement to
The full report cRecommendatiArticle 138bis-6• Definition o• All candida
previous illn• A new eval
taxes for hiPublicity and tra• Information• Maximum o
contract co• Reference
different kinBetter protectio• Evaluation Protection rathe
2.40. ResideResidential ca
The full report cRecommendatiWithout policy c• 45 000 bed
92S
t data does not altreatments are no
ement to a hospa hospital insur
can be found on: hons:
6 (domain tailoredof minimum conditate-insurees, younness, disorder of cluation should hagh level of protecansparency (doma
n of the general puof transparency bynditions, via a typon the websites
nds of hospitalizaton of persons withof the costs for amer task of national
ential care for ore for older pers
can be found on: hons: change and assumds should addition
low recommendaot recommended
pital insurance rance for persons
https://kce.fgov.be
delivery system dtions for modalitienger than 65yearscondition ppen taking into ation ain self-managemublic via different iy the private insu
pe-contract hospitaof Assuralia and
tion insurances) a chronic illness mbulatory care anl solidarity than by
older persons sons in Belgium:
https://kce.fgov.be
ming a constant bally be created in
tions in connectio
for persons wis with a chronic
e/publication/repo
design) s of the contract ts, could claim a p
account the Bemi
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urers and the natioalization insuranc the national hea
or a handicap (dond the costs not coy private insurers
in Belgium: proprojections 201
e/publication/repo
behaviour of usersthe residential se
Chronic car
on with the use of
ith a chronic illnillness or handic
ort/entitlement-to-a
to avoid the risk oprivate hospitaliza
iddelingscommiss
nels and tools onal health service (domain Error!
alth services to th
omain tailored delovered by the com(domain tailored d
ojections 2011-1-2025 (KCE-167
ort/residential-care
s (domains tailoredector for old peopl
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ness or handiccap (KCE-166-20
a-hospital-insuran
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ivery system desimpulsory health indelivery system d
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• The need fo• The increasIf there is a willi• Policies su
institutions,low-income
• The impactprovided thof new trainstitutional
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2.41. OrganOrganization o
The full report cThe recommen
2.42. After-h After-hours pr
The full report cRecommendatiThe developme• Taking into
the authorit• Different so• A unique ca
purposes • Define with
solution sho
or residential strucse in the residentiingness to curb th
upporting older pe introduction or s
e earners, developt of such policies ohat it is possible toansition probabilitlization of old peolternative, a partic
nization of childof child and adol
can be found on: hdations are includ
hours primary crimary care: whic
can be found on: hons on:
ent of an action pla account the patieties to meet the exolutions have to beall number, which
h local interested pould be provided b
ctures will be eveal sector will have
he increasing use ersons to live at strengthening of apment of home caon projected needo precise how theties could result
ople, led by a univecular attention to t
d and adolesceescent mental he
https://kce.fgov.beded in the second
care: which soch solutions? (K
https://kce.fgov.be
an in collaborationents’ needs, the dxpense, the requie combined, takinh offers the advan
parties whether thby the 1733 telep
n more acute aftee to consider the uof residential struhome for as lon
a long term care inare or other forms ds for additional bese policies would
from studies thersity group and fhe need for qualif
ent mental heaealth care: study
e/publication/repopart of the report
lutions? KCE-171-2011)
e/publication/repo
n with all stakeholdoctors’ desires, thred changes in leg
ng into account thentages of simplicit
he 1733 calls shohone operator wh
Chronic care
er 2025. It is thereuneven growth of uctures (domain tang as possible cnsurance, adminisof sheltered houseds in the residen
d impact the transhat analyzed pilofinanced by the Nfied personnel is r
alth care: study y of literature and
ort/organisation-oft (KCE-175-2012)
ort/afters-hours-pr
lders concerned the possibilities to gislation, the deone current local situty for the patient,
ould be routed to thatever type of pro
e
efore necessary tothe oldest old per
ailored delivery sycould be envisagestrative and financsing for old peoplential sector could bsition probabilities ot projects, suchIHDI (Protocol 3).required.
of literature and an internationa
f-child-and-adoles.
imary-care-which-
o solve the problecollaborate with
ntological sides auations security for the do
the switchboard ooblem
o anticipate this dersons (85+) and th
ystem design) ed (more severecial status for infoe, …). be evaluated withbetween care lev
as the ongoing
nd an internatioal overview (KCE
scent-mental-healt
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em of after-hours other health profend their uniform im
octor and the reg
of the local circle
evelopment. he current supply
e access criteria ormal caregiver, in
h the projection movels and care settg study about th
onal overviewE-170-2011)
th-care-study-of-th
in general practicessionals and strumplementation
istration of calls f
for primary care p
KCE Report 1
at local level.
to enter in residncrease in pension
odel used in this stings. The assesshe alternatives to
he-literature-a
e uctures, the capac
for system assess
problems or whet
192S
ential ns for
study, sment o the
city of
sment
ther a
KCE Reports 19
• Legislate on• Draw up theImplementation• Merging ter• Cooperatio
general pra• Creating or• Consultatio• Telephone Elements to be • Patient: info• GPs: gene
conditions, • Resources:
consultation• Communica
as soon as • Routine sta
2.43. The oThe organizati
The full report cRecommendati• To strength• To deepen
eventual lia• To expand
populations• To expand
92S
n the subject of these protocols (em
n of different solutirritories during slan agreements wit
actitioner rganized duty centon by nursing staffconsultation: prottaken into accoun
ormation on efficieral practice needdefinition of statu: adequate financns, standardized fation technologiesthey return to wo
andardized data co
rganization of mon of mental hea
can be found on: hons on:
hen the capacity to and support the
aison with specialimental health-or
s formal and inform
he legal status of cmergency mechanions adapted to lo
ack periods th local hospitals
ters: a geographicf: regulation of quatocols needed nt ent use, accurate ds to be made mus and conditions cing if unique call financing of duty cs: availability of p
ork ollection for each
mental health salth services for
https://kce.fgov.be
o provide accessie professional cozed services riented prevention
mal support service
call handlers, theiisms, referral to th
ocal situations to f
during slack peri
c distribution, favoalifications, review
information specimore attractive (Kof exercise for “afnumber solution
centers patient medical re
type of service
services for chchildren and ado
e/publication/repo
ble, responsive anmpetences in no
n, identification, i
es for both childre
Chronic car
r training and comhe first line, postpfollow-up calls, in
ods: definition of
or areas that havew of list of acts
ifying optimum seKCE-report 90), after-hours doctorsis extended, optim
cord for first-or se
ildren and adololescents in Bel
ort/the-organisatio
nd effective crisis on-specialized me
ntervention and p
en/adolescents an
e
mpetencies and thponement of consuconsultation with
triage modalities
e no hospitals
ervice for the probafter-hours work ns”, information for mization of use o
econd line service
lescents in Belgium: developm
n-of-mental-healt
and emergency cental health care
promotion for infa
nd families
he need for a protoultation etc) local circles. Mult
, existence of a t
lem, possibility of needs to be maddoctors on absenf resources durin
e providers during
gium: development of a policy s
h-services-for-chi
care to children anso as to improv
ant and toddlers
ocol to underpin t
tiple possibilities:
riage system, pos
home visits for pade more attractivnce of legal obligatg slack periods, p
g after-hours, info
ment of a policcenario (KCE-17
ldren-and-adolesc
nd adolescents e the quality of a
particularly in vu
heir decisions
ssibility of contac
atients unable to tve in terms of wotions for home vispossibility of telep
ormation for usual
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assessment, care
ulnerable and dep
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84
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e cultural and lingns of the populatih a respectful, murs (including repre+ to maintain and
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y of care providend assertive careuistic competenceons they serve ultilateral dialogueesentatives of chi strengthen cross
and quantitative de the formation of ation methods baeinforce accounta
al that a culture ofy setting up actual
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ased on internatioability, professiona
f innovation and e implementation i
Chronic care
with serious, multnvironment d adolescent men
on for the broades)+ to develop anat different institut
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e
tiple and complex
ntal health care p
r child and adoles ethical charter totional levels that a
AMHS and related
es, reflecting natiorovement and mu
ractice in the Belg
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roviders and yout
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d outcomes, to ef
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gian CAMHS syste
problems and to
th workers to acc
th services systems in formulating anlize collaboration
ffectively leverage
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em is encouraged
KCE Report 1
expand and rein
commodate the cu
m including all relnswers to the suffand network form
e regionally distri
n harmony with ehealth care to ch
d and rewarded, a
192S
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ultural
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and to
KCE Reports 19
3. SYSTEAND T
3.1. List of
LIST OF A
92S
EMATIC RETABLES OFf abbreviations
ABBREVIA
EVIEW: MEF EVIDENCfor the system
ATIONS
ETHODOLOCE
matic review
ABBREVIATIONCBT CFS/ME CSFBD CSM CSM-IP CSM-T/IP eGFR HRQoL IBS IBS-QoL PSC QoL NCD RCT SMS SMD SR SGRQ WHO
Chronic car
OGY, RES
N DEFINITIcognitive chronic facognitive comprehecomprehecompreheEstimatedHealth-reIrritable bIrritable bPain cataQuality ofnon-commrandomisSelf-manstandardsystematSt Georgworld hea
e
ULTS BY D
ION behavioural thera
atigue syndrome/mscale for function
ensive self-managensive self-managensive self-managd glomerular filtra
elated quality of lifbowel syndrome bowel syndrome qastrophising scalef life municable diseas
sed controlled trialagement supportised mean differetic review e’s Respiratory Qalth organisation
DISEASE, Q
apy myalgic encephalnal bowel disordergement gement delivered gement delivered
ation rate fe
quality of life e
ses l
nce
Questionnaire
QUALITY A
omyelitis rs
in-person by telephone and
APPRAISA
d in-person
85
AL
86
3.2. Metho3.2.1. SearchThere is a vempowerment/sthe volume of phases. During1999. Once resecond phase recent years (203.2.1.1. SearcThe following dEnglish, French3.5.5):
• The Co• OVID M• OVID E• Psychin• CINAH
3.2.1.2. SearcThe Cochrane February 2012 the year 2009. recent systemasearching for Rrecent trials.
ods h strategies vast amount of self-managementliterature anticipa
g the first phaseelevant high qualidentified relevan009 to 2012).
rch for systematiatabases were seh, Dutch or Germ
ochrane Library Medline EMBASE nfo L
rch for RCTs Library, OVID Mfor publications iThis year was c
atic reviews from RCTs from the l
literature on t of chronic diseaated, the search , systematic revility systematic rent RCTs by restri
ic reviews earched in Januar
man from the year
Medline, OVID EMin English, Frenchchosen as the se2009 were identiflast three years
patient self-efficase. In order to was segmentedews were includ
eviews were idencting the search
ry 2012 for publicar 1999 (see illust
MBASE were seah, Dutch or Germ
earch time point afied in phase 1, twould capture th
Chronic care
acy/self-manage into two ed from
ntified, a to more
ations in tration in
rched in man from as many herefore he most
3
3TbcareaInc
T3TvRInb
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e
e
3.2.2. Assessin
3.2.2.1. SystemThe methodologicbias were rated uscovered, adequatapplicable).The aseview was cond
agreed the ratingsn order for systemcriteria had to be r
• Appropriat• Descriptio
searches Psychinfo
• Quality andata asses
The results of the 3.2.2.2. RandomThe methodologicversion of the SIGRCTs was conducn order for RCTs be rated as “well c
• Randomis• Blinding o• Treatment• Descriptio
The results of the
http://www.sign.ac/
g methodologica
atic reviews cal quality of systsing the SIGN tootely addressed, ssessment of theucted by a team
s before beginningmatic reviews to rated as “well covete and clearly focu
on of methodo(e.g. Cochrane
); nd methodologicalssed and taken inquality appraisal a
mised controlled cal quality of seleN tool. The asses
cted by a team of tto be included, th
covered” or “adequsation f outcome assesst groups compara
on of dropouts andquality appraisal a
/methodology/check
al quality and ris
tematic reviews aole. This tool uses not addressed, risk of bias in th
m of two revieweg quality analysis. be included, threered” or “adequatused study questilogy; sufficiently, Medline, EMB
l strengths and wento account. are in appendix 3
d trials cted RCTs was rssment of the risktwo reviewers (FAhree of the four fouately addressed”
sment able at baseline d withdrawals are appendix 3.5.
klists.html
KCE Report 1
sk of bias
and associated ria scale of ratingsnot reported and
he included systeers (FA,GO) who
ee of the four follotely addressed”: ion; y rigorous literBASE or CINAH
eaknesses of iden
.5.1
rated using a mok of bias in the incA, GO). ollowing criteria h”:
3.
192S
isk of s (well d not matic
o pre-
owing
rature HL or
ntified
odified luded
had to
KCE Reports 19
3.2.3. Data e
3.2.3.1. SysteData from sysspecifically desdesign featuresthe following iexclusion critetypes of studiehealth-care usecomments on th3.2.3.2. RandThe DET for Rpatient numbecontrol, outcomclinical and heaof risk of bias (FA, GO) into verified in full bresolved throug
3.3. Searc3.3.1. System
3.3.1.1. IdentA total of 4,465for chronic dise
92S
extraction
ematic reviews stematic reviews igned data extrac
s and results. Thenformation: referria, and summar
es included, outcoe and a summarhe interpretation odomised controllCTs captured thers and characte
mes reported, timalth-care use andand the data exta pre-prepared
y cross-checking gh discussion with
h Results matic reviews
tified studies 5 citations on the teases were identi
and from trialsction table (DET) ie DET of the sysence, details of ry of specific intomes, results of ry of author’s conof results. led trials e following informristics, details ofme of follow-up, d interpretation of traction were per
Word® summaby each reviewer
h an independent t
topic of patient emfied in database
s were extractedn order to summatematic reviews csearches, inclus
terventions, numself-efficacy, clinnclusions as wel
ation: reference, f intervention, de
results of self-results. The asse
rformed by two rery table. Extractr. Any discrepancthird party (SM).
mpowerment intervsearches (Figure
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d into a arise key captured sion and ber and ical and l as our
country, etails of efficacy, essment eviewers ion was ies were
ventions e 1). The
mcOeT
3AdEEbF3
e
majority of citationcitations were retriOn the basis of fuexcluded. The reasons for ex
• Five studie• Four studi• One study• One as stu• Two studie
3.3.1.2. QualityAs a first step, qdetermine their suExcluded studiesEight studies 14-21
bias (appendix 3.5Final selection: 331 systematic revi
ns were excludedieved in full and reull text, 39 review
xclusion on full texes on interventiones as outcomes n
y was a duplicate udy was not a syses as intervention
ty appraisal of thquality appraisal itability for inclusi
s (n=8) were excluded o
5.1). 31 systematic revews were include
d on the basis ofeviewed in more dws were included
xt were: n not relevant 1-5 not relevant 6-9 10 stematic review 11
n was treatment of
he 39 reviews seof the 39 reviewon, using the SIG
on being judged
views ed 8, 22-50as detaile
f title and abstracdetail. and 13 reviews
f the disease 12, 13
elected ws was carried o
GN tool.
to have a high r
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87
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Figure 2 – Res
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es retrieved for moreailed evaluation: 52
evant citations identifMedline: 590; -CochrAHL: 707; -PsychInfo
cluded studies: 39
ded SR with low risk bias = 31
of systematic rev
e
Excluded after examtext: 13 Intervention: 5; Outcduplicate: 1; design
fied: 4,465 rane reviews: o: 1922
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KCE Report 1192S
KCE Reports 19
3.3.2. Rando
3.3.2.1. IdentA total of 167database searcthe basis of tireviewed in msearching. On the basis ofThe reasons fo
• Four selemen
• One stu• One stu
3.3.2.2. QuaAs a first stepdetermine their Excluded studFive studies 17,
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92S
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tified studies 75 citations of pches (Figure 3). Title and abstract
more detail and
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studies as contront of intervention) udy as outcomes udy as interventio
ality appraisal ofp, quality appraissuitability for incl
dies (n=5) 57-60 were exclud3.5.3).
n: 26 RCTs included as detail
d trials
ossible relevant The majority of cit; 37 citations weone RCT was
included and 6 Rl text were: ol group inadeq51-54 not relevant (edu
on was standard p
f the 31 RCTs sesal of the 31 Rusion, using the S
ded on being judg
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RCTs were foutations were exclere retrieved in obtained throug
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retrieved for more ed evaluation: 37 s retrieved for more
ExtexNoOuIntof Intde
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Excluded on the basis of tabstract: 1639 Population: 177 Intervention: 315 Outcome: 106 Design: 905 Language: 0 Duplicate: 136 Year of publication: 256 Type of publication: 37Excbasis of title and abstracPopulation: 148 Intervention: 893 Outcome: 60 Design: 2,169 Language: 37 Duplicate:1,124 Date of publication: 3 Language: 22
xcluded after examination oxt: 6 o control: 4 utcome: 1 tervention: 1Excluded after ethe full text: 13
tervention: 5; Outcome: 4; dupesign: 1; treatment: 2
k of bias”
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Chronic care
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igh risk of
e KCE Report 1192S
KCE Reports 19
3.4. Resultanalys
3.4.1. Interve
3.4.1.1. Two educ
Two systematidisease, withouCoster and Ninterventions dmanage their cranged from simproviding educCochrane revieevidence to anfound that eductraining, have (particularly for are promising HbA1c levels improving dise(particularly forpossible to idintervention. Wbe dependent ogroup. The autdelivery of self-In their review,management interventions fohealth care posystematic revi(e.g. educationapotential to imhealth and func
92S
ts : effectivenesis by disease entions for chron
systematic revieation ic reviews have ut focus on a specNorman, 2009 2
designed to impchronic disease (amplistic patient edation and practicews, the authorsswer their researcational programm
definite benefitreducing health cfor interventionsand reducing m
ease knowledge r decreasing reladentify what ele
Whether group or ion a number of fathors emphasise management edu, Dennis et al 20or patient educor chronic diseaolicy). Dennis et iews. Their resulal sessions and m
mprove physiologictional status, as w
ess of patient e
nic disease in ge
ews on self-man
evaluated self-cific condition. 27 analysed 30
prove patients’ kasthma in >25% ducation to self-mcal self-managems concluded tharch question. Ovemes including a fts for patients care utilisation ans for diabetes (p
medication use), and coping s
apse and readmiements are reqndividual educatioactors, including the potential imp
ucation and trainin008 31 did not secation, but rathase management
al 2008 identifits indicate that s
materials, motivatical measures ofwell as a number
mpowerment :
eneral
nagement/patien
-management in
Cochrane revknowledge and sof reviews). Interv
management progment skills. In 60%at there was inserall, Coster and form of self-manasuffering from
nd improving self-particularly for imepilepsy (particu
skills)and mentalission rates). It wuired for a suon is superior apdisease area and
portance of nurseng. et out to investigaer to identify et (relevant to Auied 141 studiesself-management ional counselling)f disease, qualityr of other clinical o
Chronic car
t
chronic
iews of skills to ventions
grammes % of the sufficient Norman
agement asthma
efficacy) mproving larly for l health was not
uccessful pears to d patient es in the
ate self-effective ustralian and 23 support
) has the y of life, outcome
mpoam3
OecfodpwmaaccPHCepinm3
OmfrcreTin
e
measures. The evprocess of care anof diabetes and hyasthma. The evidmanagement supp3.4.1.2. Patient
multipleOne RCT from Hengagement inteconditions. Patientollowing chronicdiabetes, hypertenprimary care phworkshops and phmost of the heappointments). A and calls, but withcontent. Usual cacollected by telepPatient Activation Healthy Days MChronic Disease. efficacy for self-mp=0.042). No othentervention is promake it more effica3.4.1.3. Peer-led
effect byOne larger RCT management trainrom at least onecongestive heart ecruited from a pr
The chronic disntervention (Hom
vidence favouring nd patient outcomypertension, followdence also showport by multidiscipengagement int
e conditions ochhalter et al 2
ervention in 79 ts (≥65 years), wh conditions: artnsion, depressionhysicians. The hone calls, with thealthcare they r
control interventh a general safety are acted as cohone interview atMeasure, comm
easure (HRQOLThere was a statanagement in the
er differences weremising, but requiracious. d self-managemy phone
from Jerant et ning in 415 subjee of the following
failure, depressrimary care netwosease self-manaing in on Health)
self-managemenmes was strongeswed by weaker evwed a benefit forplinary teams. tervention for eld
2010 61 tested theolder adults w
ho had to suffer fthritis, lung disen, and osteoporosintervention washe aim of trainingreceived (with ation consisted of content rather th
omparator. Self-ret baseline and 6
munication with pL-14) and Self-Etistically significane intervention groe found. The authres refinement to
ment training : eff
al 2009 62 evaects. Patients (≥4g conditions: arthsion, and diabeteork via announcemagement progra), consists of wee
t support for imprst in the disease avidence for arthritir delivery of the
derly people with
e efficacy of a pwith multiple chfrom at least two oease, heart dissis, were recruites complex, inclg patients to maka focus on methe same works
an a self-manageeport measures months and inclu
physicians scale, Efficacy for Mannt improvement inoup (post-hoc anahors conclude thatreach more patie
fect at home, no
aluated peer-led 0 years) had to shritis, asthma, Ces. Participants ments and phone mme used as
ekly sessions, wit
91
roving areas s and
self-
h
atient hronic of the ease,
ed via uding
ke the edical shops ement
were uded: CDC aging
n self-alysis, t their nts to
o
self-suffer OPD, were calls.
the th the
92
aim of masterindelivered at hoduration was 1 36-ltem short-fmental compoincluded the hospitalizationsCompared with• The Homin
effects on a• Homing in
illness ma95% CI, 0.at 1 year. MCS-36 scthe EQ VA
The authors comanagement tr3.4.1.4. Chro
two R
• The body interventionbetween di
• Overview impact of spromising possible to
• Another syimproves pfunctional s
• A patient conditions show any o
ng fundamental some (intervention
year. Primary ouform health survnent (MCS-36) EuroQol EQ-5D
s, and health care usual care: ng in on Health dany outcomes. on Health delive
nagement self-ef10-0.43) and at 6In-home HIOH
cores and led to imS (1-year ES=0.4onclude that the raining is questionnic diseases: su
RCTs
of literature shons on self-efficaciseases. of Cochrane re
self-management results for diabete
o identify the elemystematic review physiological meastatus (diabetes, hengagement inteincreased self-e
other differences c
self-management A) or via telephotcomes were the
vey‘s physical cosummary scores and visual anexpenditures.
delivered by tele
red in the home fficacy at 6 week6 months (0.17; 95
had no significanmprovement in on
40; CI, 0.14-0.66). cost-effectiveness
nable from the heaummary of two s
owed an impact cy. The impact o
eviews on self-minterventions, pa
es, epilepsy and ents required for aalso found that ssures of disease,hypertension, arthervention for eldeefficacy for self-mcompared with us
tasks. They werone (intervention Medical Outcome
omponent (PCS-3s. Secondary ounalog scale (EQ
phone had no si
led to significantlks (Effect size (E5% CI, 0.01-0.33)nt effects on PCnly 1 secondary o
s of peer-led illnealth system perspsystematic review
of the self-manan other outcome
management shorticularly for asthmmental health. It a successful interself-management quality of life, he
hritis, asthma) erly people with
management, but sual care.
Chronic care
re either B). Trial
es Study 36) and utcomes
Q VAS),
gnificant
y higher ES=0.27; , but not
CS-36 or outcome,
ess self-ective. ws and
agement s varied
wed an ma, with was not
rvention. support
ealth and
multiple did not
•
3
3Tm•
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Peer-led illneshowed only l
3.4.2. Asthma
3.4.2.1. Self-maThree systematimanagement 34, 35,
Systematic reusual care in a
Gibson et al. 200defined into five monitoring and reeview (n=2) andn=2). The data
analysis on certaineduced hospitalis
visits (RR 0.82, 90.68, 95% CI 0.56o 0.93), nocturnaquality of life (stanung function wecombination of selplan, improves asa written action plaAn earlier review b
5 trials, and cambe achieved by eitalso state that theeffectiveness.
ess self-managemimited and short-t
anagement patiec reviews eva, 49. eviews on self-madults with asthm9 included 36 triacategories34: op
egular review (n=7 written action pwas judged hom
n outcomes: Comsations (RR 0.64, 95% CI 0.73 to 06 to 0.81), days ofl asthma (RR 0.6
ndard mean differeere little changlf-monitoring, reguthma health outcoan were not as effby Powell and Gib
me to the conclusither a written actie intensity of sel
ment training at term efficacy.
ent education intaluated patient
management educma
als with self-manptimal self mana7), self monitorin
plan but not optimogeneous enoumpared with usua
95% CI 0.50 to 0.94), unscheduleff work or school (67, 95% CI 0.56 tence 0.29,CI 0.11ed. The authorular medical revieomes. Interventiofective. bson 2003 49 on thon that optimal son plan or regulaf-management tra
KCE Report 1
home (not by ph
terventions education for
cation compared
agement intervenagement (n=15), g only (n=10), remal self manage
ugh to perform ml care, the interve
0.82), emergency d physician visits(RR 0.79, 95% CIto 0.79), and impr1 to 0.47). Measurrs concluded th
ew, and a written aons that did not in
he same topic incself-management r medical review. aining is related
192S
hone)
self-
with
ntions self-
egular ement meta-ention room
s (RR I 0.67 roved res of
hat a action clude
luded could They to its
KCE Reports 19
• Meta-analyasthma in c
Guevara et al 2the same authochildren, parencomprised sevimprovement inhealth locus of 95% CI 0.15 toand reduced th95%CI –0.33 to–0.04) and the to –0.09). • RCT on seMancuso et intervention in implemented thenrolment, intechapters addreweekly by teletool) scores froED visits. 3.4.2.2. SmalOne RCT frominteractive progthe parent or tstudy outcomeuse of oral cortlife. In both theimprovement induring the yeawas a significanintervention grcorticosteroid th0.006).
92S
ysis of educationachildren and adole2003 35 based theors, including 32 ts, or both, wereveral sessions. n self-efficacy mcontrol scales (s
o 0.57) and lung fhe number of viso –0.09), absentenumber of days
elf-management edal 2011 63 ev296 asthma pa
hrough the precedervention patientsessing asthma knphone. Trial outc
om baseline to eig
ll group interacti Watson et al 20
gram of educationhe child, or boths included 12 moticosteroids, pediae control and intn total scores on r after enrolmentntly greater reducroup (p=0.0037)herapy used per p
al interventions foescents eir publication upotrials 10. The inte
e symptom-based There was a
measures reportedstandardised meafunction (SMD 0.5sits to an emerg
eeism from schoolof restricted activ
ducation valuated a self-atients based onde-proceed modes were given a owledge and self
comes included dght week follow u
ive education 009 71 studied then about child asth, depending on tonth visits to theatric asthma QoL tervention groups
the Pediatric Ast. Compared withction in the numbe) as well as patient during the
r the self-manage
on a Cochrane reerventions were a
strategies and gmodest to m
d as coping scoan difference (SM50, 95% CI 0.25 tency departmentl (–0.14, 95% CI vity (–0.29, 95% C
-management edn social learningel of health behavworkbook contaif-efficacy, then codifference in QoLup and number of
e effect of a smahma. They targetethe age of the che emergency dep
and caregivers’ qs, there was a sisthma QoL Quest the control grou
er of visits to the Efewer courses year after enrolm
Chronic car
ement of
eview by aimed at generally moderate ores and D) 0.36, to 0.75), t (–0.21, –0.23 to CI –0.33
ducation g theory viour. At ining 20 ontacted
L (AQLQ f asthma
all-group, ed either hild. The artment,
quality of gnificant tionnaire
up, there ED in the
of oral ment (p =
3SanqthhscwOpabPoinsa3Oaauthwewdpasc
e
3.4.2.3. Psycho-Smith et al 2007adults with severenine of which werquality was generhere was considehealth outcomes, ashort-term and diconsistently confweight to the resulOne additional Rpsychological couasthma patients inby an individualisPsychological couone hour sessionsntervention groupscores also signifafter intervention (3.4.2.4. Culture-One systematic reasthma programmasthma education understanding mehrough home viswere adapted to educators fluent inwas limited to eviddrawn. However, programmes or uadults and asthmstudy indicated achildren.
-educational inte50 performed a s
e or difficult asthre included in at rally considered perable variation inadmissions, QoL,d not include theirmed by sensitlts. The need for fCT by Sun et a
unselling intervenn China. There wsed self-managemunselling was cons. Asthma knowlep three months aicantly improved (p<0.001). -specific programeview from Baileymes in ethnic m modules (identify
edications, barrierssits with follow u
suit the ethnic n a particular diadence from four Rthe culture-specif
usual care in all ma knowledge sca statistically sig
erventions systematic reviewhma. The authors
least one meta-apoor, many trials n trial design. Mo, and psychologice most at-risk pativity- and subgfurther research isal 2010 70 studiedntion delivered in
were four educatioment plan develonducted by clinicadge scores signif
after intervention in the interventio
mmes y et al 2009 22 s
minority groups. ying and monitoris to care, use of ap telephone callsgroup and were
alect if required. TRCTs and no strofic programme wtrials. Asthma qu
cores in children nificant reduction
w self-managemes included 17 stuanalysis, althoughwere small-scale
ost positive effectal morbidity) wereatients, but wereroup-analysis, as highlighted. d an educationan groups of 20 onal sessions, folloped for each paal psychologists ficantly improved (p<0.001). Mean
on group three m
studied culture-spInterventions inving asthma sympaction plans) delivs. These interven
delivered by asThis systematic reng conclusions ca
was superior to geuality of life scor
were improved. n of exacerbatio
93
nt for udies, h trial
e, and ts (on e only e also dding
l and adult owed
atient. in six in the QoL onths
pecific volved toms, vered ntions sthma eview an be eneric res in
One ns in
94
3.4.2.5. CompOne systematicomputerised included trials,focused on chilof trials recordgenerally no sclinical outcomlung function). significantly imInteractive comachieved a gretwo adult interv3.4.2.6. Asthm
RCTsThe results of th• Successful
multiple cmedical rev
• Self-managsignificant number ofinterventiontraining see
• Culture-spesymptoms,
• Computerizmanageme
Three additiona• An educat
improved p• A small gro
families re
puterised-basedc review by Buasthma patient four studied cdren. Intervention
ded hospitalisatiosignificant differenes (hospitalisatioAsthma symptom
mproved in five amputer games deater impact on asentions. ma: summary ofs he systematic revl asthma self-macomponents: patview and a writtengement shown timprovements in f visits to an ens seem more efems also related tecific programm, particularly in chzed education sent intervention paal RCTs show thattional and psychopatients’ knowledgoup interactive ededuced the num
d interventions ussey-Smith 2007
education progromputer game ns used were hetens and acute cance between intens, acute care vi
ms and asthma kand four of the designed for paesthma symptoms
f six systematic r
views may be sumanagement intervtient education, n asthma plan. to be successfufavour of self-eff
emergency depaffective. The intento its effectiveneses in ethnic mildren.
shows promise aarticularly targetedt: ological counsellige and QoL 3 monucational program
mber of ED vis
7 analyzed 9 Rrammes24. Of thinterventions anderogeneous. The are visits, but theervention and coisits, medication knowledge were h
nine trials, respediatric asthma and knowledge t
reviews and thre
mmarized as followentions are madself-monitoring,
ul intervention prficacy, lung functartment. Combinansity of self-manas (multiple sessio
minority groups
as an effective d for children.
ng intervention inths after intervenmme for children aits and the am
Chronic care
RCTs on he nine d seven majority ere was ntrol for use and however
pectively. patients than the
ee
ws: de up of
regular
roducing ion, and ation of agement
ons). improve
asthma
n China ntion. and their
mount of
•
3
3TC•BRdamhaimtwspimwre•Ewinmp0sT
e
corticosteroid motivated gro
A self-manag(workbook) anpatients’ quali
3.4.3. COPD
3.4.3.1. Self-maThree systematic COPD were eligib Patient educa
Blackstock 2007 2
RCTs evaluating defined as formal aim to improve management educhealth behavioursaction plans”. Fmprovements for wo studies. Thesessions, individuphysiotherapist) mprovements in Qwere detected, duesearch in this ar Self-managem
Effing et al 2007 33
were heterogeneonterventions weremanagement educprobability of a hos0.89). St George’ssignificantly improvThe authors recom
use in the 12oup of families. gement educationd reinforced by tity of life and heal
anagement intervreviews 23, 33, 43
le for inclusion 66,
ation delivered by 23 identified four R
self-managemedelivery of educathe knowledge
cation was defines through knowleFor didactical e
any outcome, wite results for seal or in groups, were more pro
QoL and health cue to limited sampea.
ment versus usua3 identified 14 tria
ous with regard to e also diverse, thecation vs usual caspital admission (
s Respiratory Queved (WMD=-2.58
mmend self-mana
2 months after t
on programme delephone did not lth care use.
ventions and two RCTs o68 a health professio
RCTs using didacnt education. Pa
ation on topics relaand understand
ed as “education edge, goal settingeducation there th the exception olf-management ioften delivered bomising, showin
care use. Althoughple size, the autho
l care ls (15 group compoutcomes and stu
ey can all be descrare. The interventiseven studies, OR
estionnaire (SGRQ; 95% CI: -5.14 togement education
KCE Report 1
the intervention
delivered in theprovide any bene
on self-manageme
onal ctical education anatient education ated to COPD witding of COPD. focusing on cha
g and developmewere no signi
of reduced GP visnterventions (mu
by respiratory nurng a trend towh no significant eors recommend fu
parisons). The stuudy duration. Althribed as self-on reduced the R 0.64; 95%CI 0.4
Q) scores were o -0.02) from 7 stun (such programm
192S
in a
e ED efit on
ent in
nd six was
th the Self-
nging ent of ficant sits in ultiple rse or wards ffects urther
udies ough
47 to
udies. mes
KCE Reports 19
were aimed at icessation, imprplan to manageinsufficient to deA previously puvery similar cristudies. The daeffect, or were need for rescueantibiotics was • At home prBucknall et al 2care with supexacerbations included four 4nurse, monthly and 12 monthsacute exacerbadeaths due toSecondary outGeorge’s respdepression sca5D. No differenDue to a low could be drawn• A self manWakabayashi ein Japanese p(n=42), a progrsix domain scoThe six domaiavoidance of intervention waThe usual caredomains of the
92S
mproving patient roving exercise, nue COPD exacerbaefine optimal formublished review bteria as the Effinata were unsuitab
inconclusive, fore medication wasincreased. rogramme to supp2012 68 includedpported self-manpromptly (with s0 minute individutelephone calls,
s. Patients were ation. The primaryo COPD, as astcomes were heapiratory questionale (HADS), COPnce was found in Crate of questionn. agement program
et al 2011 66 evalpatients older thaam was individua
ores on the Lung ins covered: undexacerbations w
as delivered in me group (n=43) ae LINQ that was n
management of Cutrition, inhalation
ations), but considm and contents of by Monninkhof et ng et al 2009 33 rble for meta-analyr the majority of s reduced and the
port self-managem 464 COPD patie
nagement traininsupport for 12 mual training sessio
daily diary cardsrecruited after h
y outcome was hssessed by Scotalth related qualnnaire (SGRQ), D self-efficacy scCOPD admissionsnaire completion,
mme tailored to theuated a COPD san 65 years. Foally tailored to eac
Information Needderstanding COPwith an action ponthly individual
also received edunot tailored to the
COPD such as smn technique, with ader the evidence such interventional 2003 43 was breview and includysis and did not soutcomes. Howe
e use of oral stero
ment ents and compareng to detect anmonths). The inteons at home from, and questionna
hospital admissionhospital readmissittish Morbidity Rlity of life measu
hospital anxiecale (CSES) and s or death (48% vno conclusions
e patient elf-management
or the interventioh patient accordinds QuestionnaireD, medication, eplan and nutritiosessions for six
ucation based one patient nor did
Chronic car
moking an action
s. ased on
ded nine show an ever, the oids and
ed usual nd treat ervention a study ires at 6 n for an ons and
Records. ures: St ety and EuroQol vs 47%). on QoL
program n group ng to the (LINQ).
exercise, on. The months.
n the six patients
repwd(inwred3TsTerecincahcrea0fofrym
e
eceive an action pulmonary functiowalk test), BMI, dyspnoea and exCharlson index). Tn the intervention was noted in the uesults were see
dyspnoea at 12 mo3.4.3.2. Group eThe RCT of Rice esignificant decreasThe COPD diseaeducation sessionecruited through
consisted of a sinformation about cessation counseland monthly follohospitalisations anchange in SGRQ.elated hospitalisa
and 0.48 per pati0.15–0.52; p=0.00or patients withrequency of COPyear follow-up. Thmale making it diff
plan or booklets.on test, dyspnoea
ADL score, boxercise capacity BThe total LINQ scgroup compared
usual care group en favouring theonths and ADL ateducation et al 2010 69 founse on COPD hospse management ns compared wit Veterans Affairngle one- to oneCOPD, direct obslling, encouragemow up calls. Stund ED visits resp After 1 year, the
ations and ED visient in disease m01). A relatively si severe COPD
PD hospitalizationhe study populatioficult to generalise
Study outcomesa scale, exerciseody mass indexBODE index, SGcore at 12 monthsto baseline (p<0.(p<0.05). Similar
e intervention gt six months.
nd a group educatpitalisations and Eprogram was de
th usual care inrs medical cente education sessservation of inhale
ment of regular exudy outcomes inpiratory medicatio
e mean cumulativesits was 0.82 per
management (diffeimple disease ma
significantly reds and emergencyon consisted of ve to a ‘real world’ p
s included LINQ se capacity (six mx, airflow obstruRQ and comorbi
s significantly impr03), whereas a der statistically signiroup for BODE
tion program to haED visits. elivered through gn 761 COPD pares. The intervesion including geer techniques, smxercise, an actionncluded COPD-reon use, mortalitye frequency of COr patient in usualerence, 0.34; 95%anagement prograduced the compy visits by 41% aveterans and waspopulation.
95
score, minute
ction, idities roved ecline ficant
and
ave a
group atients ention eneral oking
n plan elated , and OPD- care % Cl, amme posite at one s 98%
96
3.4.3.3. COP
• Self-managresults givesignificant A systemadmission large RCTCOPD adm
• One RCT managemedaily living
• One largetelephone months.
3.4.4. Diabet
3.4.4.1. EducIndividual and g2 diabetes wererespectively. • Individual pA first systemeducation for pstudies, six wcomparator. Taddressed a wsuch as diabcomplications, generally low ainterventions, wpatients with a WMD -0.3%, difference betw• Group-bas
PD: summary of 3
gement educationen the heterogenimprovements weatic review fouand improving S
T, supported self-missions or death.in elderly Japane
ent program impand symptoms a
e RCT concludesupport reduced
tes
cational intervengroup-based patiee evaluated by Du
patient education atic review by Dpatients with type
with usual care ahe individual pa
wide range of selfbetes control, motivational and nd there were no
with the exception baseline HbA1c>95% CI -0.5 to
ween group and inded patient educat
3 systematic rev
n interventions leeity of the designere recorded for Qnd some benef
St George Respir-management at
ese patients founproved patients’ at six months. ed that group e
hospital admissi
tions ent education meauke et al 2009 32
Duke et al 2009e 2 diabetes. Thand three with gatient education f-management asexercise, glucosbehavioural strat
o significant differeof a benefit rega
>8% (education v-0.1, p=0.007).
dividual educationtion
views and 3 RCT
d usually to incons and interventioQoL and health cfit in reducing ratory Questionnahome had no e
d that individualisinformation, activ
education with fions and ED visi
asures in adults wand Deakin et al
9 32 evaluated ine authors identifgroup education was face to fa
spects of type 2 dse monitoring, tegies. Study quaences between anrding glycaemic c
vs usual care, threThe authors fo
n.
Chronic care
Ts
onclusive ons. Non care use.
hospital aire.In a effect on
sed self-vities of
follow-up ts at 12
with type 2009 28,
ndividual fied nine
as the ace and diabetes diabetic
ality was ny of the control in ee trials, ound no
TecTineMsFsasrea3EdesgaSohlidtas
e
The second systeeducation for patiecomparing group-There was a signtervention groupeducation programMeta-analysis wassignificantly reducFasting blood glusignificantly reducand the need fosignificantly improecommend furthe
a small number of 3.4.4.2. EducatiEducational and diabetes were revievaluated a widesessions, self-mogames and summa focus on the 25 Small to moderaoutcomes were obhad no theoreticakely to be effica
different aspects argeted interventsuccessful.
ematic review by ents with type 2 dbased education
gnificant improvep at four months inmme: difference 0s possible for sevced glycated haemucose levels andced, as was systor diabetes medicoved in a meta-er research to conf studies. ional and psychopsychosocial inteiewed by Hampsoe spectrum of
onitoring blood gmer diabetes camp
RCTs. ate improvementbserved with the inal basis for their acious if they de
of diabetes manions (tailored to s
Deakin et al 200iabetes. The authwith routine treatment in patient n one RCT: score.3; 95% CI 0 to 0.veral outcomes: Gmoglobin (from 4 d body weight atolic blood pressurcation. Diabetes -analysis of fournfirm their finding
osocial interventerventions for adon et al 2001 36. Tinterventions suc
glucose training, ps were summari
ts in various dnterventions. Over development. Inmonstrate the in
nagement. It remspecific patient g
KCE Report 1
9 28 focused on ghors report on 11 tment or no treatempowerment in
e in favour of the g6; p<0.001.
Group-based educmonths to two ye
t one year werere at four to 6 mknowledge was
r RCTs. The aus, which are base
tions olescents with ty
The 62 included stch as family the
diabetes club, ised descriptively
diabetes manageer half the intervennterventions are nter-relatedness omains unclear whroups) would be
192S
group trials, ment. n the group
cation ears). also onths
also uthors ed on
ype 1 tudies erapy video , with
ement ntions more
of the hether more
KCE Reports 19
3.4.4.3. Cultu
• Systematicreligious be
Hawthorne et diabetes in a 20analysable dataimproved glycamonths), and (clinical or pawhereas there knowledge, longSarkisian et al for older Caucafour non-RCTs adults, and fou3 studies in Afrwas not possicontrol was repin one study. interventions arbaseline, and wage-group. Thebeneficial. • Evaluation
managemeRosal et al 201self-managemeLatinos with tycognitive theoryphase of 12 weCourse materiaculturally tailoreopera. Outcomknowledge (usi
92S
ure-specific educ
c reviews of inteeliefs, taking into aal evaluated cu
008 review 37. Of a. Compared with
aemic control (at fknowledge scor
atient-related) weare short term beg-term benefits re2003 46 focused asian, African Amwere identified. O
r studies (30%) wrican American anble. Improved gl
ported in five RCT The authors fre most successfuwhen the intervente involvement o
of a theory-baent intervention 1 77 evaluated a
ent intervention vype 2 diabetes. y and was a yea
eekly sessions andals were simplifieded activities like f
me measures incng a subset of ite
cation
erventions tailoredaccount the targelture-specific heathe 11 included tr
h usual care, the four and six montres. No other s
ere found. The enefits for glycae
emain unclear dueon specific self-m
merican or LatinoOnly 50% of the
were in Caucasiannd five in Latino pycaemic control
Ts. A QoL improvfound indicationsul in patients with tions are specific f
of spouses and
ased, literacy- a
theory-based, liteversus no interve
The interventionar-long program cd a follow-up pha
d to address literafood bingo, food cluded HbA1c aems from the Audi
d toward the cuet group’s literacy alth education inrials, ten compriseinterventions sign
ths, not significansignificant improvauthors conclude
emic control and de to a lack of datamanagement intervo adults. Eight RC
studies focused n populations; theopulations. Meta-with intervention
vement was only s that self-manapoor glycaemic cfor the patient’s cadult children w
and culture-tailore
eracy- and cultureention in 252 lown was based onconsisting of an ise of 8 monthly scy needs, and thepreparation, and
nd lipid panel, dit of Diabetes Kno
Chronic car
ltural or skills type 2
ed meta-nificantly tly at 12 vements ed that, diabetes . ventions CTs and on older ere were -analysis n versus reported agement control at culture or was also
ed self-
e-tailored w-income n social-ntensive essions. ere were d a soap diabetes owledge)
acT4pad(dfacims3
•
•
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e
and a 17-item toochange. There was a signif4 months (intervenp<0.01), although at 12 months (p=differences in diap=0.001), blood
dietary quality (p=at (p=0.003), anconclude that litmprove diabetes sustain improveme3.4.4.4. Diabete
Results on esystematic revo The first o
were no educationThe excecontrol at
o The secoin producimprovingknowledgrecommebased on
A review coobserved wiadolescents w
Culture –speco Evidence
scores wculture s
ol to assess self-e
ficant difference intion −0.88 −1.15 this difference de
=0.293). The intebetes knowledgeglucose self-mo
=0.01), kilocaloriend percentage ofteracy-sensitive, control among lowents are needed.
es: summary of 5
education in typeviews. one found that stusignificant differe
n) and control greption was the pat baseline. ond one concludecing significant img fasting bloodge and reducing end further researn a small number ooncludes that smth educational
with type 1 diabetecific education in de for improvemenwas found on thspecific needs. A
efficacy for dietar
n HbA1c change to −0.60 vs contr
ecreased and lostrvention resulted
e at 12 months (onitoring (p=0.02)es consumed (p<f saturated fat (
culturally tailorew-income Latinos
5 systematic rev
II diabetes pati
udy quality was gences between iroups (group eduatient group with
ed that group edumprovements in fd glucose level
systolic blood prch to confirm theof studies. mall to moderat
and psychosoces. diabetes nt in glycaemic ce usefulness of
A review found s
ry and physical ac
between the grourol −0.35 −0.62 to t statistical signific in significant chp=0.001), self-eff), and diet, incl
<0.001), percentap=0.04). The aued interventions s, but that strateg
views and one R
ents differ betwe
generally low and ntervention (indiv
ucation or usual cthe poorest glyca
ucation was succefavour of self-effils, HbA1c, diapressure. The aueir findings, whic
te improvementscial interventions
control and knoweducation tailore
hort term benefit
97
ctivity
ups at 0.07,
cance hange ficacy uding ge of
uthors can
ies to
RCT
een 2
there vidual care). aemic
essful icacy, betes
uthors h are
s are s for
ledge ed to ts for
98
glycaeremain
o The iglycaeappea
o There tailorediabetother improv
3.4.5. Heart f
3.4.5.1. EducThe systematiceducational intcommonly didaconsiderable vsynthesis difficuefficacy, clinicastudies, indicatstatistically signknowledge. Sewhere there waThe most effecheterogeneity oteaching combone medium de3.4.5.2. Self-mJovicic et al 20that provided importance of dgiven by nurseanalysis showe
emic control and dn unclear. nterventions is
emic control. The rs beneficial. is furthermore e
d self-managemes knowledge andminor endpoints)
ved short term.
failure
cational intervenc review of Boydterventions for hactic sessions covariation in inteult. A significant im
al, and healthcareting at least somnificant improvemlf-efficacy showe
as continued telepctive educational sof the data but a cined with video o
elivered alone. management int06 38 identified sithe patient with
daily weighing, diee with follow up ed that the interven
diabetes knowled
most successfulinvolvement of sp
evidence from onment intervention
d blood glucose s), whereas HbA1
tions de et al 2011 26
heart failure patieonducted by nursrventions and omprovement in at
e use) was observme benefit. Know
ment in the 8 studid a significant im
phone contact six strategy could no
combination of inteor CD-ROM woul
terventions x RCTs on self-m
h information onetary restrictions visits or telepho
ntion:
ge but long-term
l in patients wipouses and adult
ne RCT that a cimproves self-
self-monitoring (as1c was only sign
6 identified 19 Rents. Intervention
ses. However, theoutcomes, makint least one outcomved in 15 of the wledge levels shies that evaluated
mprovement in onmonths post inter
ot be identified duerventions such ad be more effect
management interv signs of heart and medication re
one contact. The
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culturally efficacy, s well as nificantly
RCTs on ns were ere was ng data me (self-included
howed a d patient ne study rvention. ue to the as verbal tive than
ventions failure,
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had a not scapabilities, s
A more recent reusual care was puesults of the idenhat self-managemmortality and increeach significance
not discussed andntervention are drAn additional RCTcounselling plus envolving 902 patiactive heart failurwas death or hesodium intake, seeducational matermanagement skillsgroup meetings wThere is no evideHF patients is modifference between3.4.5.3. EducatiBaker et al 201behavioural suppoThe “teach to godiuretic self-adjusthe patient's clinicYork Heart Assocecruited at outpat
oth any cause ho 0.44 to 0.80, p=
OR 0.44; 95% CI 0significant effect ymptom status or
eview on self-manublished by Ditewintified 19 RCTs qment reduces the eases QoL, even
e. The details of td no conclusionsrawn. T from Powell et education comparients with heart fre treatment incluart failure hospitelf-efficacy and cials in the mail bus (problem-solvingith 10 patients ov
ence from this triaore effective than n the groups was ional and behavi11 72 compared ort programme w
oal” intervention tment, as well ascian. In total, 605iation (NYHA) Clatient appointments
ospital re-admissi=0.001) and heart0.27 to 0.71, p=0.
on mortality (thr quality of life. nagement interveig et al 2010 30. Tualitatively and cnumber of hosp
n though these chthe interventions on the characte
al 2010 78 evaluared with educationfailure patients reuding diuretics. Ttalisation with sechange in QoL. ut the intervention g skills and HF edver 12 months) to al that self-manageducational mateshown across all ioural support pr
a “teach to gwith a 1-hour edincluded specific
s an individualised5 patients with heass II-IV, were ras.
KCE Report 1
ons (four studiest failure re-admis001);
hree trials), func
entions comparedhe authors discus
come to the conclpital re-admissionshanges do not alare listed by tria
eristics of a succe
ated self-managen alone in a largeequiring some foThe primary end econdary endpoinBoth groups recgroup was taugh
ducation in 18 twoimplement the ad
gement counsellinerial alone becaus
study outcomes. rogramme oal” educational ucational interve instructions to d plan developedeart failure (HF), andomised, after
192S
s, OR ssions
ctional
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al, but essful
ement e trial rm of point
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o hour dvice. ng for se no
and ntion. guide
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KCE Reports 19
Compared withsignificantly higfrom 4.8 to 5.8 p<0.006); gene(from mean 4.8p<0.001); Hearintervention vs however only 1
3.4.5.4. HearRCTs
• Self-managreduce hosoutcomes quality of lif
• Educationaoutcome, spatients. Hidentified ddifferent meffective th
• One educashort-term outcomes.
3.4.6. Hypert
3.4.6.1. CompSaksena 2010computer-basedinterventions hastudies were incould not be desufficient to chathe Health Beli
92S
h the control (1-gher improvementwith the interventeral and salt kn8 to 7.6 for the rt failure related no change in th
month, and no st
rt failure summars
gement interventispital re-admissiosuch as mortalityfe or self-efficacyal interventions self-efficacy, healtHowever the mostdue to the hetero
media (e.g. verbahan one medium inational and beha
benefits in sel
tension
puter-based inte0 87 identified fivd interventions foad to be completenternet-based (weemonstrated in anange health behaief Model (definin
-hour education),ts in all outcomestion, vs from 5.0 toowledge (p<0.00intervention vs 5Quality of life (fre control group (trong conclusions
ry of three syste
ons for heart failuons but less evidey, functional capa. improve at leasth care use) in tht effective educat
ogeneity of the daal teaching and Cn isolation. avioural support lf-efficacy, self-c
erventions ve projects (10 or subjects with hed on site, under ebsites accessibleny of the studies aviours, although ng five elements
, the interventions: self-efficacy (ino 5.4 in the contro01); self-care beh5.2 to 6.7 for the rom 58.5 to 64.6(p<0.001). Follow can be made.
ematic reviews a
ure patients was ence was found fabilities, symptom
t one outcome e studies on heational strategy caata but a combinCD rom) would b
programme.conclare and quality
publications) evhypertension. Twguidance, where
e over several mothat the interventindividual compoon which an inte
Chronic car
n led to ncreased ol group, haviours control,
6 for the w-up was
and two
found to for other
m status,
(clinical rt failure
annot be nation of be more
luded to of life
valuating wo of the
as three onths). It tion was
onents of ervention
sIn3BbthctrcthocOthp••
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should act in orden one trial, blood 3.4.6.2. BehavioBoulware et al 20behavioural intervhan usual carecounselling and trraining on their consider counselherapy for the maof self-monitoringcounselling was coOne additional RChree interventionpatients: home BP mon a behavioura
telephone inte the behaviour
interventions. At 24 months, copatients with BP behavioural intervemonitoring groupntervention groupsystolic and in dia6.9 to -0.9 mm Hailored behaviourBP, and diastolic BA second trial by tncluding 588 patiprimary care provi On level one
computer-gen
er to change healpressure control woural intervention001 25 pooled the entions. The anafor decreasing
raining courses leown. Although
ling to be an ianagement of hypg of blood pressonsidered insufficCT by Bosworth s versus usual c
nitoring 3 times weal intervention (bervention), ral intervention plu
ompared with thecontrol was 4.3
ention group, 7.6p, and 11.0% (p. Similarly, there astolic BP in the cHg). In conclusionral telephone inteBP at 24 months rthe same author 7
ents with hyperteders included in t
e, primary care pnerated decision s
th behaviours) wewas improved (p<ns results of 15 RC
lysis indicated thablood pressure.
ed to better resulthe evidence ismportant additiopertension. The esure and on traicient. et al 2009b 74 cocare in a sample
eekly, bimonthly, tailore
us home BP mon
e usual care grou3% (95% CI, -4.% (CI, -1.9% to 1CI, 1.9%, 19.8%was only a sign
combined group (n, combined homervention improverelative to usual c73 was a 2-level clension who were he study.
providers receivedsupport (designed
ere positively affe<0.001).
CTs on patient-ceat counselling is b
The combinatiolts than counselli
s limited, the aun to pharmacolo
evidence on the bining courses w
ompared the effece of 636 hyperte
d, nurse-adminis
itoring two behav
up, the percenta5% to 12.9%) in7.0%) in the hom
%) in the comificant improveme
(-3.9 mm Hg; 95%me BP monitoringed BP control, syare. luster randomisedbeing followed b
d, at each visit, ed to improve guid
99
ected.
entred better on of ng or
uthors ogical enefit ithout
cts of ensive
stered
ioural
ge of n the
me BP bined ent in %CI, -g and ystolic
d trial, by the
either deline
100
concordantinterventionrecommenthe point of
• On level 2,delivered bhypertensio
The results shopressure controreminder contro3.4.6.3. Hype
RCTs
• One systeblood preslimited evicourses for
• Another interventionwith hypert
• In a singlehome BP myears).
• Another RCproviders, of both sho
3.4.7. Angina
3.4.7.1. PsycMcGillion et al the benefit of pangina. Outcomfunctioning. Onheterogeneity o
t medical therapn for primary cdations about hyf care during each, patients receivedbehavioural telepon treatment.
owed no significanol in the interventiool group. ertension: summs
matic review did ssure and of trainidence for the cr decreasing bloodsystematic revns are not sufficietension. e RCT, the combmonitoring showed
CT concluded thanor a behavioura
ow better efficacy
a
ho-educational i2004 41 was the o
psycho-educationames were symptonly four RCTs wof outcome meas
py) or simply acare providersypertension decish patient visit. d usual care or a hone intervention
nt differences in aon groups compa
mary of two syste
not find any benning courses withcombination of cd pressure. iew concluded
ent to change hea
bination of a behad positive results
at neither decisional telephone interthan usual care.
interventions only eligible systeal measures in paoms, symptom-relwere found eligibsures used preve
a reminder. Thesupplied patient
sion support deliv
bimonthly tailoren (9 modules) to
mount of change ared with the hype
ematic reviews a
nefit of self-monitout counselling. Tcounselling and
that computealth behaviours of
avioural interventon blood pressure
n support for primrvention or a com
ematic review focuatients with chronated stress, and
ble for inclusion ented any data sy
Chronic care
e active t-specific vered at
d nurse-improve
in blood ertension
and two
toring of There is training
er-based patients
tion with e (for ≥2
ary care mbination
using on ic stable physical and the
ynthesis.
OfoamreoN3Pe
3
3Trem•
•
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One included RCound the intervenand experiencing months. Althoughespective patient
of methodological No RCTs were ide3.4.7.2. Angina:Psycho-educationevidence for impro
3.4.8. Stroke
3.4.8.1. Self-maTwo recent systeeview, summarise
means of self-man Korpershoek
from a RCT tstroke patienmanagement
Jones et al 2040, as their revmanagement self-efficacy swell by the lac
Cadilhac et al 20seven South Austr a generic se
self-managem a stroke self-
only being dtargeted stroinformation).
CT evaluated grontion group to be s
fewer angina eph each study re
educational meaflaws, making the
entified for patient: summary of onal stress manaoving angina symp
anagement progrematic reviews wed available evidenagement programet al 2011 40 conthat clearly demonts but overall tprogrammes in th
011 39 come to theview found some
programmes onscales such as Fck of available RC011 82 randomiseralian hospitals, tolf-management p
ment programme),-management prodelivered by prooke-specific info
oup stress manasignificantly more pisodes compareeported some poasures, the includee results unreliables with angina.
ne systematic revagement interveptoms
rammes were identified wence on the furthemmes after a stroknclude that, althoonstrates self-suffhere is a lack his area. e same conclusioemerging evidenc
n self-efficacy ouFalls Efficacy ScaCT evidence. ed 143 stroke pao either standard cprogramme (Stan, ogramme (havingofessions skilled ormation each
KCE Report 1
gement sessionsrelaxed, less stre
ed with controls aositive effects oed trials had a nue.
view ntion showed
which, as part of ering of self-efficake:
ough there is evidficiency is beneficof evidence on
n as Korpershoekce for a benefit of
utcomes measureale but was limite
atients, recruited care or: ford chronic con
g greater contact in stroke, prov
week and revi
192S
s and essed at six
of the umber
some
their acy by
dence cial to
self-
k et al f self-
ed by ed as
from
dition
time, viding isiting
KCE Reports 19
Primary outcomSecondary outcHealth Educatimood at 6 monthe stroke pro(p=0.18). The abut the differenc3.4.8.2. StrokThere is a lackself-efficacy afte
3.4.9. Irritable
3.4.9.1. Self-m
• No evidencOne systematicMany of theminterventions (eoutcomes usedbenefit for manadministered cstructured patieto draw reliable• InterventioOne tree-arm Rmanagement (eighty-eight paintervention gro
the CSM dCSM delivsessions,
The interventionurse practition
92S
mes were recruitmcomes were position Impact Questnths from programogramme and 3authors concludedces in outcomes w
ke: summary of tk of evidence thaer stroke.
e bowel syndrom
management
ce from one systec review from D
m suffered frome.g. home-hypnosd did not allow sty of the tested secognitive behavioent education, howe conclusions. ns by trained nurs
RCT by Jarrett et aCSM) program f
atients were randoups: elivered in-person
vered over the te
on was delivered ners. It covered
ment, participationive and active engtionnaire, and chmme completion.
38% completed d that the stroke were not significatwo systematic rat self-manageme
me (IBS)
ematic review Dorn et al. (2010
methodological sis, self-help suptatistical analysis
elf-management inoural therapy, swever, but the av
ses (face-to-face aal 2009 80 assessfor patients with domised into us
n by trained psychelephone but incl
in nine one houfour themes –
n, and participangagement in life u
haracteristics of QOverall, 52% co
the generic inteprogramme was nt. reviews and oneent programmes
)29 identified 11 flaws. The va
pport or guideboo. There was an nterventions suchself-help guidebovailable data is ins
and telephone) sed a comprehens
IBS. One hundual care or one
hiatric nurses, uding three face
r sessions by pseducation, diet
Chronic car
t safety. using the QoL and ompleted ervention
feasible
e RCT improve
studies. ariety of oks) and possible
h as self-ook and sufficient
sive self-red and of two
to face
ychiatric (identify
paOcAg
Nwin3RsothinIBinteSHTsamposea
e
problems in their and cognitive behOutcome measurecognitive beliefs, IAt 12 months thegroups:
symptom sco25.6, p<0.001(CSM-T/IP) (-improvements(12.2, p=0.010
No difference waswas shown to be en improving IBS s3.4.9.2. StructurRingström et al school”) with writtold). The IBS schheory of nursing an functional GI disBS school consnformation was aested by questionSeverity Scoring Hospital Anxiety aThe IBS school gsignificantly greateand p=0.04 at 6 mmonths and p=0.perceived knowledof HRQoL were astructured patientenhance knowledganxiety in IBS pati
diet), relaxation (havioural (based ements included: BS symptom scorere were significa
ore: CSM session1), CSM sessions28.4, p=0.006) ves in QoL compare0) and CSM-T/IP
s noted between teffective either desymptoms and Qored education 2010 86 comparen information on
hool was based oand a biopsychossorders, and tooksisted of six wean IBS guide booknnaires: perceived
System, IBSQoLnd Depression Scroups (vs the wr
er reduction in IBSmonths) and gastro.02 at 6 monthsdge of IBS (p<0.0also significantly it group educationge of IBS, and iments.
(abdominal breathon individual asgastrointestinal
re, psychological ant improvement
ns delivered in-pes delivered by telersus UC (-9.5); ed with usual care(11.90, p=0.029 v
the intervention grelivered by telephool.
ed structured panly in 143 IBS paon the self-efficacsocial model consk a cognitive–behaeekly 2-hour grok. The efficacy ofd knowledge (VisuL, Visceral Senscale. itten information
S symptom severiointestinal-specific), as well as gr
001 at 3 and 6 moimproved. The aun is superior to mprove gastro-int
hing, music relaxassessment) stratesymptom score, distress. ts in both interve
erson only (CSM-ephone and in-pe
e (IBS QoL in CSvs UC 7.4) roups: this prograone or totally in-pe
atient education atients (18 to 70 cy theory, the gesidered to be impoavioural approachoup sessions. Wf the interventionsual Analog Scale)sitivity Index, and
only group) showty (p=0.06 at 3 mc anxiety (p<0.00reater improvemeonths). Several asuthors conclude twritten informatio
testinal symptoms
101
ation) egies. QOL,
ention
-IP) (-erson
SM-IP
amme erson
(“IBS years
eneral ortant
h. The Written s was ), IBS d the
wed a onths 1 at 3 ent in spects that a on to s and
102
3.4.9.3. CognOerlemans et aintervention forThe Interventioon their personfeedback focudysfunctional ccognitive–behathe Dutch IBS pto receive theoutcomes inclufunctional boweSyndrome qualcatatstrophising(PSC). At four intervention gimprovement inhowever these up. 3.4.9.4. IBS s
• The systemmanagemelimitations
• A comprehor telephonsymptoms
• A structuresymptom sat 6 month
• Cognitive bterm for im
nitive behaviour al 2011 76 evaluatr the self-manageon group receivednal electronic diarused on IBS cognitions, and aviour therapy. Sepatient associatio
e CBT interventiouded IBS symptel disorders (CSFlity of life questiog thoughts measweeks there wasroup (χ2= 4.08n the interventioneffect differences
summary of one
matic review concent interventionsand the heteroge
hensive self-manane with 3 face to fand QoL at 12 mo
ed education progseverity, anxiety, ks. behaviour therapyproving IBS Qol a
for self-manageted a cognitive-be
ement of IBS patid situational feedbries over the cou
complaints, caavoidance behaveventy-six IBS p
on and through theon (n=37) or ustoms measured
FBD), Qol assesseonnaire (IBS-QoLsured by The Pas greater overall
8, p<0.05).and n than in control s were not seen
systematic revie
cludes that there is for IBS, givneity of the interve
agement interventface sessions shoonths.
gramme (“IBS Schknowledge and se
y for IBS had a and pain improvem
ement ehavioural therapents in The Nethback from a psycurse of three weeatastrophising thiour and was baatients recruited eir GPs were randsual care (n=38)
by Cognitive sed by The Irritabl) and the degree
ain CatastrophisinQoL improvemensignificantly mogroup (χ2=5.44, at the three mont
ew and three RC
is weak evidence ven the methodentions under stution delivered faceowed improvemen
hool”) showed beneveral aspects of
weak effect at thment.
Chronic care
py (CBT) herlands. chologist eks. The houghts, ased on through
domised ). Study cale for e Bowel
e of pain ng scale nt in the re pain p<0.05), th follow
CTs
for self-dological dy. e to face nt in IBS
nefits for f HRQoL
he short-
3
3T(Tincpskcims3Ckcinmnmasah5ASm(thspd
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3.4.10. Kidney di
3.4.10.1. EducatiThe systematic multicomponent e
The data was hetenterventions (indicare worker ± edphone calls) appesignificant improvknowledge retentioconsider the evmplementation of stages of chronic k3.4.10.2. Self-maChen et al 2011 84
kidney disease paclinic in Taiwannformation, reinfomaintenance of thnurses, dieticiansmeetings, weekly addition, specific stage, including absolute estimatedhospitalisations. S50% and all-causeAt the end of the SMS group than ml/min, p<0.05). T18.50% vs 44.47he intervention gsignificant differeprogrammes couldisease progress
isease
ional interventionreview of Masoeducational interverogeneous and tividual or groupucational materia
eared to be genervement for at leon and delay in thvidence sufficieeducational inter
kidney disease. anagement supp
4 conducted a RCatients (CKD, stag. The SMS pr
orced learning inche therapy, imples and volunteertelephone suppormeasures were
lectures or discud glomerular filtraSecondary endpoe mortality. Duratiostudy, the absoluin the control g
There were also f%, p<0.05). EGFroup vs 33.3% innces were founld play an imposion and reduci
ns n et al 2008 4
ventions with psytrial quality was loeducation delive
als ± psychosociarally beneficial, wieast one of thehe onset of dialysient to advocaterventions, especia
port (SMS) CT with 54 incidenges III to V), recrurogramme includcentives and encoemented by a murs. There were rt and a support g
implemented foussions. The prition rate (eGFR) ints included eGon of follow-up wa
ute eGFR was siggroup (29.11+/-20fewer hospitalisatiR reduction <50%n the control grond. The authors ortant role in slong morbidity of
KCE Report 1
42 included 22 Rychological elemeow in many casesered by trained hal support ± folloith 18 trials reporte outcomes sucs therapy. The aue development ally for patients in
ntal predialysis chited from an outp
ded the provisioouraging self-careultidisciplinary tea
monthly face-togroup twice a monr patients by dismary endpoints change and numbFR decrease of as 12 months. gnificantly higher i0.61 vs 15.72+/-ions in the SMS g
% was seen in 3.7up (p<0.05). No
conclude that owing chronic kf late-stage pat
192S
RCTs ents).
s. The health ow up ting a
ch as uthors
and early
hronic atient
on of e and am of o-face nth. In sease were
ber of up to
in the 10.67 group 7% in other SMS
kidney tients.
KCE Reports 19
However thesesize meant the differences. 3.4.10.3. NurseChow et al 20Overall, 100 randomised to programme. Thplanning protocnurse-initiated shared objectivDisease Qualitywere collected after completioweeks post discNo significant standard care iled case manag3.4.10.4. Kidne
RCTs
• There is interventionthe disease
• A small Refficacious morbidity.
• There is manageme
3.4.11. Chroni
3.4.11.1. OnlinBerman et al 2self-care techn
92S
e results must be study was not po
e-led case mana010 85 focused opatients were reither routine ca
he intervention ccol (involving famtelephone follow-
ves and reinforcingy of Life Short Foat T1 (dischargen of the case macharge).
between-group is not significantlygement in this patey disease summs
weak evidence ns for chronic kide. RCT concludes
in CKD, slow
no evidence foent.
ic pain
ne mind-body se2009 64 studied iniques in 78 adult
viewed with cauowered sufficiently
agement on HRQoL in perrecruited after are or to a nursconsisted of a c
mily members) an-up regimen, withg of health-relatedorm (KDQOL- SFe, baseline), T2 (anagement interv
differences wery worse – regarditient group. mary of one sys
to support muldney disease patie
that self-managwing disease pro
r a HRQoL be
elf-care techniqun a RCT the efficts over 55 years
tion as the smally to detect betwee
ritoneal dialysis phospital admissi
se-led case manacomprehensive did a standardised
h the aim of achid behaviours. The
FTM) was used. T(6 weeks post disvention) and T3 d
re found, implyiing HRQoL – tha
tematic review a
ticomponent eduents in the early
gement support ogression and r
nefit of nurse-le
ues cacy of online miof age with chron
Chronic car
sample en group
patients. on and agement ischarge 6-week eving of e Kidney The data scharge, data (12
ing that n nurse-
and two
ucational stage of
can be reducing
ed case
ind-body nic pain.
PeafomweInEv6(wsToinmrethu3
•
3
3TsFtog
e
Patients were recreither the intervenan introductory moor change, basedmodule at least oweeks. Outcomesefficacy Questionnventory-Short FEpidemiologic Stuversion of the CES6), self-awarenessPAQ) developed
with and use of thstudy). The authors foundoutcomes except ncreases in confmanage pain for teported by the inhe intervention mup was only 6 wee3.4.11.2. Chronic
self-car
The efficacy oa waiting list)
3.4.12. Painful mdiseases
3.4.12.1. Self-maThe systematic reself-management Face-to-face grouo heterogeneity thgenerally favoured
ruited from commntion or a waiting odule describing a on a 6-stage mo
once and to use ts included self-efnnaire), pain inteForm), depressioudies Short DepreS-D), anxiety (6-its of responses tofor the purpose o
he intervention (su
d no significant beAwareness of R
fidence with usinthe intervention g
ntervention group may have an immeeks and overall noc pain: summaryre techniques
of online mind-boremains unclear.
musculoskeletal cand arthritis)
anagement progreview of Du et alprogrammes (16 p sessions were he potential for md the intervention.
munity based settinlist. The interventa problem-solving
odel. Participants wthe website at leafficacy (measure
ensity (measuredon (measured wession Scale (CEtem State-Trait Ano pain (Pain Awaof this study), selurveys developed
etween-group diffResponses to Pg non-medical s
group. Reductionsat log on and log
ediate impact on o strong conclusioy of one RCT on
dy self-care techn
conditions (inclu
rammes l 2011 8 identifiedin arthritis and 3most commonly ueta-analysis was The results show
ngs and randomistion website compg approach to plawere asked to try ast once a week d with the Pain
d with the Brief with the Centre
ES-D 10), a shortnxiety Inventory; Sareness Questionf-care and satisfafor the purpose o
ferences for any oain. There were elf-care techniqus in mean pain sg off also suggesreducing pain. Fo
ons can be drawn.Online mind-bo
niques (compared
uding rheumatic
d 19 RCTs evalu in chronic back pused (15 studies)limited, but the re
wed that
103
sed to prised nning each for 6 Self-Pain
e for tened STAI-nnaire action of the
of the also
es to cores
st that ollow-.
ody
d with
uating pain). . Due esults
104
• the evidenc• there are
managemesignificant)0.17, p=0.00.41 to -0.1CI: -0.27 to
Shin et al 2010studies found thhad a positive ethe effect waAdditionally themaking it difficudid show sigmeasurement evidence to adolder adults wita reduced neeHowever only s3.4.12.2. EducNiedermann etrheumatoid arthstudies were behavioural strefficacy with inshort- or long-tterm and indicaRiemsma et al 31 studies. Exconclusion thatobtained by Durheumatoid artbenefits regardpsychological spain. These res
ce in chronic backsignificant long-
ent in arthritis (4) particularly for re0003) at 6 month17, p=0.0003), ano -0.07, p=0.0006)0 47 reviewed 12 Rhat psychosociallyeffect on pain redas not always e results reportedult to quantitativelgnificantly improvtools. This revie
dvocate consistenth osteoarthritis, hed for and bett
short-term outcomcational intervent al 2004 44, rehritis (11 studies)
purely educatiorategies. Three ofnconsistent resultterm health statusations for long-term2003 45 used broxtensive meta-an, in contrast to the et al 2011 8, edu
thritis. In the shoding disability, jostatus, and depressults do not agre
k pain is insufficie-term (from 6 m4-month meta-aneducing pain (SMDhs and 12 monthsnd reduction in dis) at 12 months. RCTs in older aduy focused intervenuction and functiosignificant compd from the reviely assess the outve in four RCew concludes thnt implementationhighlighting the poter managed pha
mes were assessetions viewed patient e, with a focus on
onal, whereas ff the 11 studies ts. The authors fs but improvemenm psychological badly similar selecnalysis was pere results for self-mucation did not leaort term howeveoint counts, patssion, as well as ae with those of N
nt, months) benefits nalysis results wD=-0.29;95% CI:-s (SMD=-0.29, 95sability (SMD=-0.
ults with osteoarthntions (self-manaon improvement, apared with the ew were often qucome effect. Self
CTs, all used at there may bn of self-manageossible benefits rearmacological tred.
education in adulong-term effects
four adopted cospecifically target
found no improvent of coping in th
benefits. ction criteria and idrformed and ledmanagement progad to long-term ber, there were siient global assea positive trend re
Niedermann et al
Chronic care
of self-were not 0.41 to -5% CI: -17; 95%
hritis. All gement) although
control. ualitative f-efficacy different e some
ement in egarding eatment.
ults with s. Seven ognitive-ted self-
ement in he short-
dentified to the
grammes enefits in gnificant
essment, egarding 2004 44,
wR3
•
•
•
3
3Otr7omuQAtrimsaaTtop
e
who identified the Riemsma et al 2003.4.12.3. Musculo
systema
Self-managemfor arthritis pimprove self-e
There is a lacback pain.
Two systemaarthritis show psychological
3.4.13. Fibromya
3.4.13.1. PsychoOne RCT from Lreatment program75 years old). Theof which 5 were edmeasures were fuusing a SociodeQuestionnaire, ChAnxiety Inventoryreatment were ompairment, days stiffness, anxiety, absolute risk reducand the number neThe authors conclo short-term impatients.
same studies bu03 45 such as disaoskeletal painfulatic reviews
ment programmespatients particulaefficacy. ck of evidence fo
atic reviews on esome short-term
status). There is
algia
educational inteLuciano et al 20mme with usual ce intervention conducational and 4 functional status aemographic Quehronic Medical Coy. Significant diffebserved (favourinnot feeling well, and depression (ction with the inteeeded to treat waude that a 2-monprovements in t
ut did not report tability and joint coul conditions sum
s might be benefary in managing
or the effect of se
educational intervm effects (coping,
no impact on hea
erventions 011 75 comparedcare in 216 fibromnsisted of nine wefocused on autogand some clinicaestionnaire, the onditions Checkliserences betweenng the interventiopain, general fatmedium effect siz
ervention was 36.1s 3 (95% CI: 2.0-4th psychoeducatithe functional s
KCE Report 1
he same outcomeunts.
mmary of four
ficial at the short g pain, disability
elf-management i
ventions in rheumdisability, joint co
alth status.
a psychoeducamyalgia patients (eekly 2-hour sessenic training. Outl measures, asseFibromyalgia Im
st, and The Staten the groups at on) regarding phytigue, morning fatze in most cases)1% (95% CI 23.3-4.3). onal intervention
status of fibromy
192S
es as
term y and
n low
matoid ounts,
tional (18 to sions, come essed mpact e Trait
post-ysical tigue, ). The -48.8)
leads yalgia
KCE Reports 19
3.4.13.2. InternWilliams et al management (Patients (≥18 criteria for fibrowebsite took a(educational lecto help with sydesigned to fibromyalgia). Pfurther coachedAfter 6 monthoutcomes i.e. p(p<0.01) measuproportion of pabaseline to 6 group (p<0.008secondary outcPatient Global I3.4.13.3. Fibro
• The efficacterm impro
• Internet-ba(pain intenChange).
92S
net-based self-h2010 79 investig
(versus usual cayears, fulfilling t
omyalgia) were rean educational sctures; education,ymptom managem
facilitate adaptiPatients were end. hs, the intervenphysical functionalured by the Seveatients reporting months was also
8). There were nocomes fatigue, sleImpression of Cha
omyalgia: summa
cy of psychoeducovements in functioased self-help intensity, physical fu
help interventionsgated internet-enhare) in 118 subthe American Cecruited from a nself-help format , behavioural, andment; and behavive life style c
ncouraged to use
ntion significantlyl status (p<0.03) (
erity Scale of the a 30% decrease o significantly gro significant betweep problems, moange. ary of two RCTs
cational interventonal status).
ervention: improveunctioning, Patien
s hanced behavioubjects with fibroollege of Rheumetwork of 54 clincomprising 13 m
d cognitive skills doural and cognitichanges for me the site, but w
y improved the (SF-36) and averaBrief Pain Inventoin mean pain sco
reater in the inteween-group differeood) with the exce
s
tions is moderate
ed symptoms at 6nt Global Impres
Chronic car
ural self-myalgia.
matology ics. The modules designed ve skills
managing were not
primary age pain ory. The ore from
ervention ences in eption of
e (short-
6 months ssion of
3
3Tswapd(tFfoctrO3Binmotua(cfrDTeptrewa
e
3.4.14. Multiple s
3.4.14.1. PsycholThomas et al 20sclerosis (MS) pawere broadly definaddress cognitionpatients with cogndisability (three sthree studies).
Few positive outcoound cognitive recognitive outcomerials suggested tOverall no definite3.4.14.2. ChronicBarlow et al 200ntervention (waitmanagement courof six weekly 2-hutors. The coursapply new skillscomparison grourom MS longer anData (questionnairThe authors foundefficacy (effect sizp=0.005). There wrends towards impefficacy (ES 0.16, was maintained aand few outcomes
sclerosis
logical intervent06 48 evaluated tients, based on
ned and included tThe review was
nitive impairment (tudies), with MS
omes were reporehabilitation appees in patients withat psychothera
e conclusions can c disease self-ma09 81 randomisedting list; control rse (CDSMC; intehour group sessise was largely in. Some patientsp); these patientsnd were less anxres) were collected that the interveze (ES) 0.30, p=were no other staprovement on depp=0.04) were no
t 12-month follows reached statistic
tions psychological int16 studies. Psycthose that addresstratified by subg
(three studies), w(seven studies),
rted across the inears to have soth cognitive impa
apy may be benebe made from thianagement courd 216 subjects w
group) or a cervention group). ons, delivered bnteractive, encous chose not to s were on averagious than patients
ed at baseline, 4 mention improved s=0.009) and physatistically significapression (ES 0.21oted. Some improw up but overall ecal significance.
terventions in muchological intervenss mood and thosegroups of MS patith moderate to se, and with depre
ncluded trials. Oneme positive effeairment. One of eficial for depress review. rse with MS, to eithechronic disease The course cons
y pairs of traineuraging participan
attend the CDge older, had sufs who chose to atmonths and 12 moself-managementsical status (ES
ant changes. How, p=0.05) and MSvement in self-eff
effect sizes were
105
ultiple ntions e that tients: evere
ession
e trial ct on three
ssion.
er no self-
sisted ed lay nts to DSMC ffered ttend. onths. t self- 0.12,
wever, S self-ficacy small
106
3.4.14.3. Multipone R
• There is edisease secognitive o
• One RCT fself-manag
3.4.15. Chroni(CFS/M
3.4.15.1. Self-hWearden et al the effectivenescollaboratively rehabilitation pweek period divprogramme aimpatterns, concewhich was revsupportive listepatient could dPragmatic rehacourse of the apparent at the3.4.15.2. Self-h
summOne study on pfatigue, sleep aterm.
ple sclerosis: suRCT
evidence that cogelf-management cooutcomes. found improvemegement course
ic fatigue syndroME)
help programme2010 67 conductess of a pragmaticwith patients s
rogramme consisvided into five facmed towards a grentration componviewed at each ning where a the
discuss their concabilitation improve
18 week interve 70 week follow uhelp programmemary of one RCTpragmatic rehabiland depression bu
ummary of one s
nitive behaviouraourses have little
ent self-managem
ome/myalgic enc
e ed a three arm sinc rehabilitation acsuffering from Csted of 10 sessioe to face and five
raded return to acnent using a follo
session. The seerapist provided acerns and the th
ed fatigue, sleep aention but these up. e for chronic fatigT itation showed so
ut these benefits w
systematic review
l approaches andor no effect on m
ent and self-effica
cephalomyelitis
ngle-blind RCT totivity programme
CFS/ME. The prons delivered ovee telephone sessioctivity, regulation ow up manual anecond study gron environment w
hird arm was usuand depression dubenefits were no
gue syndrome:
ome benefit on imwere no sustained
Chronic care
w and
d chronic mood and
acy after
o assess devised
ragmatic er an 18 ons. The of sleep nd diary
oup was here the
ual care. uring the o longer
mproving d at long
3
3GF(flciningpathaSeePinnRaSTc3
AinP(
e
3.4.16. Chronic n
3.4.16.1. Online fGhahari et al 201Fatigue Severity Parkinson's or polyers, adverts or control (routine canteractive elemenntervention was dgroup experience participation and iat three months ushe Fatigue Impacand stress (DepreSocial Support Indessential computexception of the PPhysical Subscalen favour for the inno significant diffeRepeated-measurand the informatioScale and the ActThe authors conclcontrol. 3.4.16.2. Fatigue
RCT An online fatigue nformation alone Physical SubscaleQoL, activity parti
neurological con
fatigue self-man10 65 enrolled paScore of 4) du
ost-polio syndromeemails and 95 p
are), information ont) or online fatigudeveloped from a f
and facilitators. mpact of fatigue. sing the Personal ct Scale. Secondaession, Anxiety andex), self-efficacyter skills (self-cPersonal Wellbeine of the Fatigue Imnformation-only grerences between res ANCOVA shoon-only groups imtivity Card Sort (pude that there is
in chronic neuro
self-managemenfor two primary ou
e of the Fatigue Iicipation and impa
nditions - fatigue
agement prograatients with extreue to chronic ne) in a RCT. Subjparticipants were
only (as the interveue self-managemface-to-face versiPrimary outcomThey measured Wellbeing Index,
ary outcomes wend Stress Scale)y (Generalised Seconstructed meang Index at post-tmpact Scale at folroup over the conthe three groups
owed that the fatproved over time
p<0.05), in contraslittle benefit for th
rological conditio
nt programme offeutcomes (PersonaImpact Scale) of act of fatigue).
KCE Report 1
amme eme fatigue (mineurological condects were recruite randomised to eention, but withou
ment. The active oon and included bes were QoL, acpre-test, post-tes Activity Card Sorre depression, an, social support (elf-efficacy Scale
asurement). Withtest (p=0.034) anlow-up (p=0.035)ntrol group, there on primary outco
igue self-manageon the Fatigue Im
st to the control ghe intervention ove
ons: summary of
ered little benefital Wellbeing Indexthe primary outc
192S
imum ditions ed via either ut any online blogs, ctivity
st and rt and nxiety (Duke ) and
h the nd the , both were
omes. ement mpact group. er the
f one
t over x and omes
KCE Reports 19
3.4.17. Schizo
3.4.17.1. PsycChan et al 200patients, recruitand their care(groups of 3psychoeducatiopoints were imand 12 months • For patient
for the RO(p=0.003) Psychiatricand at allTreatment into his or h
92S
ophrenia
hoeducation in a09 83 evaluated psted from the psychegivers. The pati36 and 37 paonal programme mediately after th(post-3) after the
ts, significant grouOMI score (Rating
and post-2 (p=c Rating Scale ) l time points (p<Attitudes Questi
her illness).
a Chinese settinsychoeducation fohiatric out-patientients (and careg
atients) to eithe(10 sessions ov
he intervention (pintervention.
up differences weg of Medication In=0.012) time poscore at the pos<0.01) for the ITonnaire that ass
ng or Chinese schizodepartment of a
givers) were rander usual care ver 3 months). Foost-1), 6 months
ere detected by thnfluences ) at theoints, the BPRSst-2 (p=0.017) timTAQ items (Insiesses a patient's
Chronic car
ophrenic hospital, domised or the
ollow-up (post-2)
he U-test e post-1 S (Brief
me point, ght and s insight
•
Tp3Op
e
For caregivertest for the Sand post-2 (p(p=0.033) andBurden Interv
The authors concpatients and carer3.4.17.2. SchizopOne small RCT fpsycho-education
rs, significant grouSES (Self-efficacy<0.001) time poind post-2 (p<0.02iew Schedule ) sc
cluded that the inrs, but that the effephrenia summaryfrom China foundfor both patients
up differences wey Scale) score atnts, the level of sa21) time points, acore at the post-2 tervention had poect might not last ry d a short-term beand carers.
ere detected by tht the post-1 (p=0atisfaction at the pand the FIBS (Ftime point (p=0.0
ositive effects onas long as 12 mo
enefit (<12 month
107
he U-0.007) post-1 Family 043). both
onths.
hs) of
Study
Albanoal 200
Baileyal 200
Barlowand E2004
Blacksand Webst2007
Boren2008
Boulwet al 2
Boydeal 201
108
3.5. Searc3.5.1. Quality
Internal valid
Appropriate and clearly focussed question?
o et 08
adequately addressed
y et 09 well covered
w llard adequately
addressed
stock
ter well covered
et al well covered
ware 2001
well covered
e et 1 well covered
h strategy, quay appraisal for in
dity
Is a descriptioof the methodology described?†
poorly addressed
well covered
poorly addressed
well covered
adequately addressed
well covered
adequately addressed
ality appraisal ancluded systema
on Literature searches adequate?‡
adequately addressed
well covered
adequately addressed
adequately addressed
poorly addressed
adequately addressed
adequately addressed
and data evideatic reviews
Study quality assessed and taken into account?§
not addressed
well covered
not addressed
well covered
not addressed
adequately addressed
not addressed
Chronic care
nce tables
Ove
Was pooling of data appropriate? (If applicable)
Biaminion(++)
not applicable -
appropriate ++
not applicable -
not applicable ++
not applicable -
appropriate ++
not applicable +
e
erall assessment
as nimisat?
+, + or -
If biased, hwould biasresults?
results coufavour eitheinterventionstudies withrisk of biasincluded
results coufavour eitheinterventionstudies withrisk of biasincluded
results coufavour eitheinterventionstudies withrisk of biasincluded
results coufavour eitheintervention
how s affect
Types of study included
uld er n if h high were
SRs, RCTs, non-RCTs
RCTs
uld er n if h high were
RCTs, non-RCTs
RCTs, andCCTs
uld er n if h high were
RCTs, non-RCTs
RCTs, CCTs
uld er n if
RCTs
Research questions answered?
yes
yes
yes
d yes
yes
yes
yes
KCE Report 1
High quality systematic review?
Comme
no Weak method
yes Cochrareview
no
Descripof methodlacking
yes Well conducreview
no
Literatusearch not inclEmbase
yes
yes
192S
ents
dology
ane
ption
dology
cted
ure did ude e
Study
BusseSmith 2007
Costeal 200
Davis 2011
Deakinal 200
Dennial 200
Ditewial 201
Dorn e2010
Du et 2011
KCE Reports 19
Internal valid
Appropriate and clearly focussed question?
ey-et al adequately
addressed
r et 09
adequately addressed
et al poorly addressed
n et 09 well covered
s et 08
adequately addressed
ig et 0 well covered
et al well covered
al well covered
92S
dity
Is a descriptioof the methodology described?†
well covered
well covered
poorly addressed
well covered
well covered
well covered
well covered
well covered
on Literature searches adequate?‡
adequately addressed
well covered
adequately addressed
well covered
adequately addressed
well covered
adequately addressed
Poorly addressed
Study quality assessed and taken into account?§
not addressed
well covered
not addressed
well covered
not addressed
well covered
adequately addressed
well covered
Chronic car
Ove
Was pooling of data appropriate? (If applicable)
Biaminion(++)
not applicable +
not applicable ++
not applicable -
appropriate ++
not applicable ++
not applicable ++
not applicable ++
appropriate ++
e
erall assessment
as nimisat?
+, + or -
If biased, hwould biasresults?
studies withrisk of biasincluded results coufavour eitheinterventionstudies withrisk of biasincluded
validity of runcertain glack of detamethods an
how s affect
Types of study included
h high were
uld er n if h high were
RCTs
SRs
results is given ail of nd QA
RCTs, non-RCTs
RCTs, CCTs
SRs, RCTs, non-RCTs
RCTs
RCTs, CCTs
RCTs
Research questions answered?
yes
yes
no
yes
yes
yes
yes
yes
High quality systematic review?
Comme
yes
PubmeERIC, CINAHPsychinclintrials
yes
no
no informaprovidemethodof revie
yes Cochrareview
yes
yes Well conducreview
yes
yes
Literatusearch includemedlineEmbasedatabasbut hansearchi
109
ents
d,
L, nfo, s
ation ed on dology ew
ane
cted
ure only d e and e ses
nd ng
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Duke 2009
Effing 2007
Gibsoal 200
Guevaet al 2
Hampet al 2
Hawthet al 2
Iverseal 201
Jones2011
Jovicical 200
Korpeek et a2011
110
Internal valid
Appropriate and clearly focussed question?
et al well covered
et al well covered
n et 09 well covered
ara 2003 well covered
son 2001 well covered
horne 2008 well covered
en et 0 well covered
et al well covered
c et 06
adequately addressed
rshoal well covered
dity
Is a descriptioof the methodology described?†
well covered
well covered
well covered
well covered
well covered
well covered
poorly addressed
adequately covered
well covered
well covered
on Literature searches adequate?‡
well covered
well covered
well covered
adequately addressed
well covered
well covered
well covered
well covered
well covered
Adequately addressed
Study quality assessed and taken into account?§
well covered
well covered
well covered
poorly addressed
well covered
well covered
not addressed
not addressed
adequately addressed
adequately addressed
Chronic care
Ove
Was pooling of data appropriate? (If applicable)
Biaminion(++)
appropriate ++
appropriate ++
appropriate ++
appropriate ++
appropriate ++
appropriate ++
not applicable +
not applicable ++
appropriate ++
not applicable ++
e
erall assessment
as nimisat?
+, + or -
If biased, hwould biasresults?
validity of runcertain glack of detamethods an
how s affect
Types of study included
RCTs, CCTs
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RCTs, CCTs
RCTs, CCTs
RCTs, CCTs
results is given ail of nd QA
RCTs
RCTs, non-RCTs
RCTs
RCTs, non-RCTs
Research questions answered?
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
KCE Report 1
High quality systematic review?
Comme
was carout.
yes Cochrareview
yes Cochrareview
yes Cochrareview
yes
yes HTA
yes Cochrareview
no
yes
yes Well conducreview
yes
192S
ents
rried
ane
ane
ane
ane
cted
Study
Masonal 200
McGillet al 2
Merindet al 2
Monniof et a2003 Niedenn et a2004 Powelal 200
Riemset al 2
Sarkiset al 2Shin e2010 Smith 2007
SolomM, 200
KCE Reports 19
Internal valid
Appropriate and clearly focussed question?
n et 08 well covered
lion 2004 well covered
der 2000
adequately addressed
inkhal adequately
addressed
rmaal adequately
addressed
ll et 03 well covered
sma 2003 well covered
sian 2003 well covered
et al well covered
et al well covered
mon 08 well covered
92S
dity
Is a descriptioof the methodology described?†
well covered
well covered
adequately covered
well covered
well covered
well covered
well covered
well covered
adequately addressed
well covered
poorly addressed
on Literature searches adequate?‡
well covered
well covered
poorly covered
well covered
well covered
well covered
well covered
adequately addressed adequately addressed
well covered
poorly addressed
Study quality assessed and taken into account?§
adequately covered
well covered
not addressed
adequately addressed
adequately addressed
well covered
not addressed
poorly addressed poorly addressed adequately addressed
poorly addressed
Chronic car
Ove
Was pooling of data appropriate? (If applicable)
Biaminion(++)
not applicable ++
not applicable ++
not applicable -
appropriate ++
not applicable ++
not applicable ++
not applicable ++
not applicable ++
not applicable ++
appropriate ++
not applicable -
e
erall assessment
as nimisat?
+, + or -
If biased, hwould biasresults?
validity of runcertain glack of detamethods an
validity of runcertain glack of QA
how s affect
Types of study included
RCTs
RCTs
results is given ail of nd QA
RCTs, non-RCTs
RCTs, non-RCTs
RCTs
RCTs, non-RCTs
RCTs
RCTs, non-RCTsRCTs, non-RCTsRCTs, non-RCTs
results is given
ALL except editorials, letters, proceedings, not
Research questions answered?
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
Yes but conclusion not in line with the findings
High quality systematic review?
Comme
yes
yes
no
Search limited EmbaseCochraOld revas searwere ra1997
yes
yes Embasesearche
yes search in Dec 2
yes
yes
yes no Embin searc
yes
no
111
ents
by no e or
ane. view rches an in
e not ed
ran 2000
base ch
Study
Thomaal 200
Yehle 2010
112
Internal valid
Appropriate and clearly focussed question?
as et 06 well covered
et al well covered
dity
Is a descriptioof the methodology described?†
well covered
poorly addressed
on Literature searches adequate?‡
well covered
adequately addressed
Study quality assessed and taken into account?§
well covered
not addressed
Chronic care
Ove
Was pooling of data appropriate? (If applicable)
Biaminion(++)
not applicable ++
not applicable +
e
erall assessment
as nimisat?
+, + or -
If biased, hwould biasresults?
validity of runcertain glack of detamethods an
how s affect
Types of study included
peer reviewed
RCTs
results is given ail of nd QA
RCTs, non-RCTs
Research questions answered?
yes
yes
KCE Report 1
High quality systematic review?
Comme
yes Cochrareview
no
Poor reportinstudy method
192S
ents
ane
ng of
dology
KCE Reports 19
3.5.2. Data e
Reference (author, year, country)
Patiepopu(inclucriter
Bailey et al. 2009 Australia
Asthm Childadultgroupasthm
Blackstock and Webster 2007 Australia
COP Particto hadiagnCOP
92S
extraction table o
ent ulation usion ria)
Settin(primacare, seconcare)
ma
dren and s of minority ps who have ma.
Primarand secon
D
cipants had ve a formal
nosis of D
Primarand secon
of included syste
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
4 RCTs
ry
dary
10 RCTs (13 publications)
ematic reviews
n criteria
Type of intervention and definition
Patient education An education programme is defined as a programme which transfers informatiabout asthma in anform.
)
Patient education. Patient education was defined as formal delivery of education on topicrelated to COPD with the aim to improve the knowledge and understanding of
Chronic car
Description of interventions
on ny
RCTs involving comparisons of specifically developed cultuorientated asthmprogrammes witheir local geneasthma educatiprogrammes or usual care, suchindividual asthmeducation sessidelivered in participant’s owdialect.
cs
Education had tbe delivered by health professioand it needed toinvolve at least occasion wherepatient or grouphad face to faceinteraction. Patient educatiowas categorised
e
Main positivereported
f
ure ma th ric on
h as ma ions
wn
Use of a culturprogramme wageneric progracare in improv patient knowl -asthma knowchildren, WMD1.07 to 5.53), Clinical - asthma qualitin adults, poole(95% CI 0.09 t - exacerbationstudy, reducingexacerbations (risk ratio for h0.32, 95%CI 0
to a
onal o one
e the p e
on d
Self-efficacyOnly one studyself-efficacy foeducation and any significantbetween study Clinical This review fousignificant diffebetween group
Results
e results from outcomes
Ovcon
re-specific as superior to ammes or usual ing :
edge
ledge scores in D 3.30 (95% CI
ty of life scores ed WMD 0.25 to 0.41),
s in a single g asthma in children ospitalisations .15, 0.70).
Curshospeaduminasteffeproimpof lknoexaconast
y examined ollowing
did not find difference
y groups.
und no erences ps for cognitive
Therevmarecbeneduwithconmagrotailoin b
erall study nclusion
rrent limited data ow that culture-ecific programmes for ults and children from nority groups with hma are more ective than generic ogrammes in proving most (quality ife, asthma
owledge, asthma acerbations, asthma ntrol) but not all hma outcomes.
e data from this view is insufficient to ke firm
commendations on thenefits associated with ucation for patients h COPD. No nclusions can be de as to whether
oup or individual ored education resultsbetter outcomes.
Abacus summ
This evidence is liby the small numbincluded studies alack of reported seefficacy outcomesOverall it is difficumake conclusionsregarding the effectiveness of cuspecific asthma programmes basefour RCTs when mof the statistically significant results from one study (C2008). More studies are required to addresquestion and to fuinform relevant clipractice and healtpolicy.
e
s
Self-efficacy was nimproved through patient education compared to usuahowever only one reported on self-efficacy. There were no significant differenbetween groups inhealth care utilizat
113
mary
mited ber of and the elf-s. lt to
s
ulture
ed on many
are Canino
ss this urther nical th
not
al care, study
nces n tion of
114
Reference (author, year, country)
Patiepopu(inclucriter
Boulware et al 2001
Hype
ent ulation usion ria)
Settin(primacare, seconcare)
ertension Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
15 RCTs
n criteria
Type of intervention and definition
COPD. Self-management education was defined as educatifocusing on changing health behaviours througknowledge, goal setting and development of action plans. Didactical educatiowas defined as education in a passive lecture format.
Patient education Patient-centred behavioural interventions focusing on counseling, structured training courses, and patieself-monitoring of blood pressure (BPCounseling was defined as individu
Chronic care
Description of interventions
ion
h
on
into self-management education and didactical education.
ent
P).
ual
Both counselingand training interventions wemultidimensionanature, primarilyadvocating general, commoaccepted lifestypractice changeencouraging healthy diet, weloss, exercise, atobacco cessati
e
Main positivereported
function, hospilength of stay, costs, pulmonaHRQoL or anxdepression. Health-care uTwo studies shbenefit in decrevisits in the integroup with oneshowing signifparticipants in group attendedgreater than onmonth period (group vs 84% p<0.0001). Thiintervention wagroup sessionsdays, then follo2 patients with
g
ere al in y
only yle es:
eight and ion.
Self-efficacyCounseling plufavored over caffording morehypertension c95% CI, 87 to receiving coun95% CI, 34 to alone (64%, 95 Clinical (i) Pooled resucounseling wa
Results
e results from outcomes
Ovcon
ital admissions, health care
ary function, xiety and
se howed some easing GP ervention
e meta-analysis icantly more the control
d their GP nce in a 12 (26% education control group, is study the as 2 x 2hr s on 2 separate ow up with 1 or nurse.
LikeuncprodelDisdidlikebencomma
us training was ounseling in
e patients control (95%, 99) than those
nseling (51%, 66) or training 5% CI, 48 to 77).
ults revealed that s favored over
Finsugoffeoveaddtraicouimp It san phagive
erall study nclusion
ewise there is certainty as to which ofessional should be ivering the education.
sease specific actical education is
ely to be of less nefit to COPD patientsmpared with self-nagement education.
dings from 15 RCTs ggests that counselingers BP improvement er usual care, and thatding structured ning courses to
unseling may further prove BP.
eems counseling is important adjunct to
armacologic therapy en the reduction of
KCE Report 1
Abacus summ
s
HQoL except for adecrease of GP vithe intervention gr(from 2 RCTs).
g
t
This review focusethe outcome of redblood pressure ratthan self-efficacy outcomes. There iinsufficient evidensuggest whether smonitoring of BP otraining courses aoffer consistent improvement in BPcounseling or usucare.
192S
mary
a isits in roup
ed on ducing ther
is nce to self-or lone
P over al
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Boyde et al. 2011 Australia
Heart Meanyearsmale
92S
ent ulation usion ria)
Settin(primacare, seconcare)
t failure
n age 70.6 s, 55.3%
primarsecon
Inclusion
ng ary
ndary
Types and number of studies identified
ry and dary
19 RCTs
n criteria
Type of intervention and definition
or group discussioand teaching with personalised approach, set in a non-classroom format in which individuals or groumembers might often share their personal experiences. Self-monitoring of BP was defined ashome BP monitorinperformed by the patient for the purposes of recording or monitoring BP.
Patient education. Educational interventions definas a prespecified learning activity anthe intervention waevaluated either directly by knowledge or self-care abilities or indirectly by readmission rates,mortality or QoL.
Chronic car
Description of interventions
on a
up
s ng
Included studieswere primarily “patient-centredthat is studies thwere designed tdetect the effecof changes in patient behavioon BP as a resuof the interventinot interventionwhich the healthcare provider wthe unit of analy
ned
nd as
-
,
One on one didactic patient education (12 studies) with supplementary follow up educasuch as home visits, written materials, videoand telephone cdelivered by nupredominantly.Or take home educational vide(2 studies) or CROMs (5 studie
e
Main positivereported
s
d,” hat to
cts
ur ult on, s in h-
was ysis.
usual care in imdiastolic blood(3.2 mmHg, 955.3), and systopressure (SBP95% CI, 4.1 to (ii) Pooled resucounseling watraining courseimprovement immHg, 95% C (iii) Counselingwas favored ovimprovement immHg, 95% C
ation
os calls rse
eo D-
es).
Self-efficacySelf-efficacy hasignificantly sigimprovement rstudy only (1 hsession with wcalls for 1 monmonthly for 6 mSelf-care showstatistically sigimprovement istudies (Videoone education follow up) Knowledge Knowledge lev
Results
e results from outcomes
Ovcon
mprovements in pressure (DBP)
5% CI, 1.2 to olic blood P) (11.1 mmHg,
18.1),
ults revealed that s favored over
es in n DBP (10
CI, 4.8 to 15.6).
g plus training ver counseling in n SBP (4.7
CI, 1.2 to 8.2).
BP inte
ad a gnificant reported in one hour education weekly phone nth, then months). wed a nificant n 6 out of 8 , nurse one on with telephone
vels showed a
Thevaredustuoutfor diffmoeduVermopatwasindcomtypmu
erall study nclusion
shown with these erventions.
ere was much riation in the ucational interventionsdied as well as the tcome measures usedevaluation making it
ficult to establish the ost effective ucational strategy. rbal teaching is the
ost common form of tient education but s the least effective, icating it needs to be
mbined with a second e of medium such as ltimedia.
Abacus summ
s
d
Self-efficacy showsignificant improvebut was only repoone study where tintervention was continued with telephone contactmonths post intervention. Patient knowledgelevels improved however there is nevidence from thisreview that this theimproves self-careself-efficacy.
115
mary
wed a ement rted in the
t 6
e
no s en e or
116
Reference (author, year, country)
Patiepopu(inclucriter
Bussey-Smith and Rossen 2007 USA
Asthm RCTsEnglilanguevaluuse ointeracompeducprograsthmof an
ent ulation usion ria)
Settin(primacare, seconcare)
ma
s in the sh
uage that uated the of an active puterised ational ramme for ma patients y age
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
9 RCTs
n criteria
Type of intervention and definition
Patient education vcomputer The computerised asthma patient educational programme (CAPEP) makes uof computer gameand programmes tailored to the specific features othe asthma in the individual playing tgame. This is made possible by incorporating the
Chronic care
Description of interventions
Educational interventions weguided by a theoretical modin 7 studies.
via
use s
of
the
Patient educatiohad to involve thuse of interactivcomputerised programme. This may includdidactic educatiprogramme thatprovides information abothe basics of asthma, asthmamedication, inhause, asthma triggers/allergenor the use of aneducational
e
Main positivereported
ere
el
statistically sigimprovement ithat evaluated knowledge. Clinical Three studies significantly demortality. QoL improved studies. Health –care uFour out of 12 reported signifdecreased rea NB: actual resreported in pub
on he ve
de a ion t
out
a aler
ns, n
Self-efficacyAsthma knowleFour studies oassociated witimprovements knowledge Clinical Improvement iFive out of a towere significanwith improvemsymptoms. (i) Lung functioTwo studies (a
Results
e results from outcomes
Ovcon
nificant n the 8 studies patient
reported ecreased
in 2 out of 12
use studies
ficantly admission rates.
ults not blication.
Paton withbenpat
edge: ut of 9 were h significant in asthma
n symptoms otal of 9 studies ntly associated
ment in asthma
on improvement a didactic
Inteapppatknosymevidsupobjouthoscarmefun
erall study nclusion
tient education based educational theory h evaluation may nefit heart failure tients.
eractive CAPEPs pear to improve tient asthma owledge and mptoms. However lessdence exists to pport their effect on ective clinical tcomes, including spitalizations, acute re visits, use of rescuedications, and lung ction
KCE Report 1
Abacus summ
s
e
Computerised asteducation may imasthma knowledgesymptoms. Studiehad repeated expoto using the CAPEreported significanimprovement in asknowledge. Further research ihowever needed tjustify its use in clioutcomes includinhealth care utilisatand patient self-ef
192S
mary
hma prove e and
es that osure
EPs nt sthma
s to inical
ng tion fficacy.
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Coster and Norman 2009 UK
Peopfrom healtor coincludthe cvulneor ch Includpopu
92S
ent ulation usion ria)
Settin(primacare, seconcare)
ple suffering a chronic h problem ndition, to de carers in ase of
erable adults ildren.
ded lations
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
30 Cochrane reviews
n criteria
Type of intervention and definition
patient’s own medication, allergens and/or triggers, peak flowdata, and/or symptoms into thegame to make the experience more relevant for the us
Educational and semanagement interventions by nurses. This review adoptea broad definition opatient education tinclude all interventions designed to improv
Chronic car
Description of interventions
w
e
er
website as part a video and computer patienmanagement system, or use ocomputer gamewhich teaches users how to taappropriate medications andavoid triggers using an on-scrnurse.
elf-
ed of to
ve
Patient educatioranged from geadvice or was tailored for indivpatients. Self-managemeprogrammes provided both education and practical self-management skwith some
e
Main positivereported
of
nt
of a e
ke
d
reen
education, andinteractive progassociated witin lung functioneach study) Health-care u(i) Number of hOne study whimultimedia comwas associateddecrease in ho(p=0.02) (ii) Acute care One study whicomputerised awas associatedin acute care v(iii) Rescue inhOne study whiinteractive comprogramme wawith decrease bronchodilator
on neral
vidual
ent
kills
Asthma intervThere was gooreviews) that seducation reduutilization suchhospitalisationemergency visshowed improvin children (WoThere is inconsas to whether a
Results
e results from outcomes
Ovcon
d a personal gramme) were h improvements n (p=0.02 in
se hospitalizations ch used a mputer game d with a
ospitalizations
visits ch used asthma lessons d with reduction
visits (p<0.01) haler use ch used
mputerised as associated in short-acting
r use (p=0.02)
ventions od evidence (3 self-management uced health care h as reduced s and
sits. One review ved self-efficacy olf 2002). sistent evidence action plans
-ovjudrevinaevidinteeffepro-fewconwith
erall study nclusion
ver half the reviews : ged by the Cochrane
viewers to provide dequate dence for the erventions’ ectiveness (design oblems) w SR reached nclusions h regard to the key
Abacus summ
Fewer than half threviews were founbe effective so oveeducational and smanagement progcannot be stronglyrecommended alththe diversity acrosprograms makes idifficult to generalThe majority of outcomes focusse
117
mary
he nd to erall elf-
grams y hough ss the it ise.
ed on
118
Reference (author, year, country)
Patiepopu(inclucriter
wereCOPrheumarthrieczemschizbipolastrokpain, hype
Deakin et al. 2009 UK
Type Adultdiagndiaberegargendethni
ent ulation usion ria)
Settin(primacare, seconcare)
: D, epilepsy, matoid itis, atopic ma,
zophrenia, ar disorder, e, HIV, back
rtension
2 diabetes
ts with nosed type 2 etes rdless of er or city
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
11 RCTs (14 publications)
n criteria
Type of intervention and definition
patients’ knowledgand skills to manachronic health problems. Excluded: -Psychological interventions suchas psychotherapy CBT -interventions delivered by lay people
)
Group-based patieeducation
Chronic care
Description of interventions
ge ge
or
programmes containing behavioural treatments. Interventions wedelivered througwritten or multi-media materialsinteractive sesswith professionalectures or a combination of tapproaches.
ent Group-based educational programmes whmet the followincriteria: • specific for people with typediabetes; • delivered in primary or
e
Main positivereported
ere gh
s, sions als,
these
(help patients wmonitoring of amedication) caisolation or onloptimal self-maprogramme. Diabetes Only one (Deafive reviews onpositive result education progeffective at impoutcomes and psychosocial oEpilepsy Group educatioreduce numbeimprove knowlbut evidence isnumber of trialCOPD : Interveimprove knowlreduce hospitalow number of trials available
hich ng
e 2
Results of metfavour of groupdiabetes educaprogrammes w Self-efficacy(i) One RCT, Dassessed the lempowerment months there wdifference in to
Results
e results from outcomes
Ovcon
with self-asthma an work in ly as part of an anagement
akin 2005) out of n diabetes had of group
grammes were proving clinical some
outcomes.
on might help er of seizures and
edge of epilepsy s limited by low s available. entions may edge, QoL and
al admission but good quality .
cominteEduhavpatastprointediameIt iswhaneesucHowcleawheindsupFeweffe
ta-analyses in p-based ation
were
Deakin 2003 evel of and found at 4 was a significant otal
Groor tmain pdiaimpgluandandbloand
erall study nclusion
mponents of ervention programmesucational programmesve some benefits for tients suffering from hma and are
omising for erventions for betes, epilepsy and ntal health.
s difficult to describe at elements are eded to make a ccessful intervention. wever, there is no ar evidence as to ether group or ividual education is
perior. w data on cost-ectiveness
oup-based education training for self-nagement strategies
people with type 2 betes is effective by
proving fasting blood cose levels, HbA1c d diabetes knowledge d reducing systolic od pressure levels, d the requirement for
KCE Report 1
Abacus summ
s s
improvement in disymptoms and hecare utilisation ratthan self-efficacy. Interventions for asthma, diabetes epilepsy were founbe effective often because self-management programmes are aat symptom monitsuch as blood glucwhich can empowpatient to managecondition.
There was strong evidence from onethat group-based diabetes educatiosignificantly improempowerment. Most of the outcomused in the meta-analysis resulted ftwo or three studie
192S
mary
sease alth her
and nd to
aimed toring cose
wer the e their
e study
n oved
mes
from es.
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
92S
ent ulation usion ria)
Settin(primacare, seconcare)
Inclusion
ng ary
ndary
Types and number of studies identified
n criteria
Type of intervention and definition
Chronic car
Description of interventions
secondary care• based on learner/patient-centred educati• included or excluded familyand friends; • had a minimumsix participants each group; • was a minimumof one session lasting for one hour.
e
Main positivereported
;
on;
y
m of in
m
empowerment of the group edprogramme (d0.3;95% CI 0 t(ii) Diabetes knImprovement a(standardised SMD: 1.0; 95%1.2) from 4 RC Clinical (i) HbA1c Reduction at 4(1.4%; 95% CIat 12-14 monthCI: 0.7 to 1.0) (1.0%; 95% CI3 RCTs. (ii) Fasting blooReduction at 1mmol/L; 95% CRCTs. (iii) Systolic bloReduction at 4mmHg: 95% CRCTs. Health-care u(i) Need for diamedication Reduction in n
Results
e results from outcomes
Ovcon
score in favour ducation ifference o 0.6;p<0.001) nowledge at 12-14 months mean difference
% CI: 0.7 to CTs.
4-6 months I: 0.8 to 1.9), hs (0.8%; 95% and at two years I: 0.5 to 1.4) from
od glucose 2 months (1.2
CI: 0.7 to 1.6); 2
ood pressure 4-6 months (5 CI: 1 to 10), 2
se abetes
eed for diabetes
dia
erall study nclusion
betes medication.
Abacus summ
Therefore more stare needed to conwhether group education programare more efficaciobased on patient education incorpoempowerment.
119
mary
tudies nfirm
mmes ous if
rating
120
Reference (author, year, country)
Patiepopu(inclucriter
Dennis et al. 2008 Australia
Adultyearswith oof thechroncondhypecorondiseadiabedisorasthmarthriRA) aosteo
Ditewig et al. 2010
Chrofailur
ent ulation usion ria)
Settin(primacare, seconcare)
ts aged 18 s and over one or more e following nic itions: rtension, nary heart ase, type 2 etes, lipid ders,
ma, COPD, itis (OA and and oporosis.
Primarcare
nic heart e (CHF)
Primarsecon
Inclusion
ng ary
ndary
Types and number of studies identified
ry 141 studies (study types not reported) and 23 SRs. Only studies >1990 and undertaken in Australia, Canada, The Netherlands, New Zealand, Scandinavia, UK and USA.
ry, dary
19 RCTs
n criteria
Type of intervention and definition
Chronic disease management interventions. The Chronic Care Model (Wagner 1996) was used asframework for analysis, 6 elemenof the model: self-management support, delivery system design, decision support, clinical informationsystems, communresources and heacare organisation.
Self-management
Chronic care
Description of interventions
s a
nts
n ity
alth
Organisational, professional or financial interventions fochronic diseasedelivered by nohospital professionals. Patient-mediateinterventions suas distribution oeducational materials, education sessimotivational counselling, brieintervention, community programs, self-management ancall-back remindnotices.
Studies had to describe and compare
e
Main positivereported
medication (od95% CI: 5.2 to trials
r e n-
ed uch of
ion,
ef
nd der
This review foumanagement ieffective in impprocess of careoutcomes, withevidence for dhypertension, sfor arthritis andless clear evid According to thcare model, efinterventions 1. Self-manageelement
• Patiesess
• Patiecoun
• Educ2. Delivery sys
• Multteam
• Moseffecdelivdesihypedisodise
Self-efficacyNR
Results
e results from outcomes
Ovcon
dds ratio 11.8, 26.9) from 5
und self-nterventions are proving both e and patient h the most iabetes and some evidence d asthma with ence for COPD.
he of the chronic ffective
ement support
ent education sions ent motivational nselling cational material
stem design tidisciplinary ms st evidence for ctiveness of very system gn for diabetes, ertension, lipid rders and heart ase
Evirevdisetheheainteto bengselfsupedufor nurmacar
Thifouava
erall study nclusion
dence from this view on chronic ease management in Australia primary
alth care showed the erventions most likely be effective were gaging primary care inf-management pport through ucation and training GPs and practice
rses and linking self-nagement support in
re plans.
s systematic review nd that current
ailable published
KCE Report 1
Abacus summ
n
The focus of this rwas on effective cdisease managemAustralian primaryhealth care. It idensome important finbased on the ChroCare Model but deon effective self-management interventions werereported making itdifficult to assess aspects make up successful interve
Although there wesome positive findof self-manageme
192S
mary
review chronic ment in y ntified ndings onic etails
e not t what a
ention.
ere dings ent
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
The Netherlands
AdultyearsdiagnCHF,of sevdisealevel group
92S
ent ulation usion ria)
Settin(primacare, seconcare)
ts aged >18 s and nosed with , regardless verity of the
ase, literacy or ethnic
p
and te
Inclusion
ng ary
ndary
Types and number of studies identified
ertiary
n criteria
Type of intervention and definition
Self-management refers to the individual’s ability tmanage symptomstreatment, physicaand psychosocial consequences andlifestyle changes inherent to living wa chronic conditionto affect the cognitive behavioural and emotional responsnecessary to maintain a satisfactory QoL, sa dynamic and continuous procesof self-regulation isestablished.
Chronic car
Description of interventions
to s,
al
d
with n,
ses
so
ss s
effectiveness ofself-managemeinterventions (inany format, i.e. written, verbal, visual, audio) wstandard care designed for CHpatients implemented byany health professional or leader. Self-management interventions could be integrain a formal CHF(disease-management) program.
e
Main positivereported
f ent n
with
HF
y
lay
ated F
Clinical (i) mortality One study out assessed mortsignificant reduof the interventhe rate of deaobservation ye(ii) quality of lifOnly 6 out of 1measured QoLsignificant impQoL in intervencompared with Health-care u(I) All-cause horeadmissionsTwo studies (AGiordiano 2009assessed all-creadmissions rsignificant decof the intervenAnother study 2008) reportedlower proportiointervention pareadmitted. (ii) CHF-hospitTwo studies (soutcome) out oassessed CHF
Results
e results from outcomes
Ovcon
of 9 that tality reported a uction in favour tion group on
aths per ear (p=0.006). fe 4 studies that
L reported rovements in ntion groups
h controls.
se ospital
Atienza 2004, 9) out of 8 that
cause hospital reported
crease in favour tion-group. (Wakefield
d a significantly on of combined atients were
talization rate same as above of 4 that F-
stumeweavalieffemaintemohoschrhosquawith
erall study nclusion
dies show thodological aknesses making idation of the ectiveness of self-nagement
erventions on ortality, all-cause spital readmissions, ronic heart failure spitalization rate and ality of life in patients h chronic heart failure
Abacus summ
.
interventions for Csuch as reduced hospital readmissiand improved QoLdifficult to make strecommendationsself-management interventions for thchronic disease grMany of the includstudies had short up periods and theinstruments used assess self-management (QoLtools) may not be adequately validatmeasure an effectimproved or worseself-efficacy. In future, well-desstudies on CHF arrequired to determthe independent eof self-managemeinterventions and different combinatinterventions on cand patient reportoutcomes
121
mary
CHF
ions L, it is trong
s for
his roup. ded follow e to
L
ted to t of ened
igned re
mine effects ent
tions of linical ed
122
Reference (author, year, country)
Patiepopu(inclucriter
Dorn et al 2010 USA
Irritabsyndr Adultyears
ent ulation usion ria)
Settin(primacare, seconcare)
ble bowel rome (IBS)
ts (>18 s) with IBS
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
11 studies (9 RCTs, 2 non-RCTs)
n criteria
Type of intervention and definition
Self-management Self-management strategies typicallyinclude educationamaterials, as well acognitive behavioural approaches to increase patients’ knowledge, bolsteself-efficacy, and encourage self-management behaviours.
Chronic care
Description of interventions
y al as
r
Comparison of oor more self-management related interven(IBS education programme withweekly sessionssingle educationclass, audio CDbased home hypnosis sessioself-administerecognitive behavioural therapy, self-heguide book, support groups)a control (includstandard medictreatment and/owait list group).Psychological therapies whichmay or may notconsidered a component of smanagement wexcluded unlessthe psychologictherapy was primarily self-administered asmeans of strengthening
e
Main positivereported
hospitalizationsignificant redufavour of the ingroup.
one
ntion
h 6 s, nal
D-
ons, ed
elp
) to ding cal or
h t be
elf-were
s cal
s a
Self-efficacy (i) IBS knowledOne RCT (Rinreported greateimprovements knowledge in preceived a strueducation comeducation boo74 on VAS vs months 73 vs 4 Clinical (i) IBS SymptoScore (IBS-SSOne RCT (Rinreported greateimprovements patients who restructured IBS compared withbooklet (3 mon-21 vs. -6; p=0change of -32 p=0.04). Another RCT agreater symptopatients assigncare plus self-mcompared with
Results
e results from outcomes
Ovcon
rate described uctions in ntervention-
dge gstrom 2009) er in IBS
patients who uctured IBS
mpared with IBS klet (3 months: 40, p<0.001; 6 40, p<0.001)
om Severity SS) gstrom 2009) er in IBS-SSS in
eceived a education
h IBS education nths: change of 0.06; 6 months: vs -13,
also reported om relief in ned to usual management
h usual care
Selsupapppatadmbehachbenusuachrelihelevidsuphominco Mastume
erall study nclusion
lf-management pport interventions didpear to benefit IBS tients with a self-ministered cognitive havioural intervention hieving the largest nefit compared with ual care (72% vs 7% hieved adequate ef) followed by a self-p guidebook. The dence for patient pport groups and me hypnosis was onclusive.
ny of the included dies were limited by thodological flaws.
KCE Report 1
Abacus summ
This review showesome promising smanagement interventions for IBsuch as self-administered cognbehavioural therapself-help guideboostructured patient education, howevemany studies wereunder-powered wismall patient numand at risk of bias due to a lack of bl
192S
mary
ed elf-
BS
nitive py, ok and
er e ith bers often
inding.
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
92S
ent ulation usion ria)
Settin(primacare, seconcare)
Inclusion
ng ary
ndary
Types and number of studies identified
n criteria
Type of intervention and definition
Chronic car
Description of interventions
self-care.
e
Main positivereported
alone. (ii) IBS SeveritOne non-RCT2006, n=25) redecrease in theScale (53% vsat 3 months repatients who rehome hypnosiscompared with(standard med (iii) Adequate rOne RCT (Lacreported superrelief (respond7.4%; p< 0.05)respectively asadministered cbehavioural theself-monitoringAnother RCT rrelief (76.7% v0.05) in patienusual care plusmanagement cusual care alon (iv) Clinical gloimprovement One RCT(Lackreported higheimprovements assigned to secognitive beha
Results
e results from outcomes
Ovcon
ty Scale (Palsson
eported a e IBS Severity
s. 26%, p<0.05) espectively in eceived a s programme
h controls dical care)
relief ckner 2008) rior adequate ers 72.0% vs. ) in patients ssigned to self-cognitive erapy (CBT) vs
g control. reported higher vs. 21.2%; p< ts assigned to s self-compared with ne.
obal
kner 2008) er clinical global
in patients elf-administered avioural therapy
erall study nclusion
Abacus summ
123
mary
124
Reference (author, year, country)
Patiepopu(inclucriter
Du et al 2011 China
Muscpain Adultyearschronmuscpain whicharthrior fibback shouneck and tsymppersithan
ent ulation usion ria)
Settin(primacare, seconcare)
culoskeletal conditions
ts (aged ≥18 s) with nic culoskeletal conditions h include itis(OA, RA romyalgia), pain, lder pain, pain, etc.,
the ptom of pain sts for more 3 months
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
19 RCTs
n criteria
Type of intervention and definition
Self-management Studies of interventions that integrated systematic therapiinto a self-management or secare program wereincluded. Comparison was usual care or waiting-list control
Chronic care
Description of interventions
es
elf-e
.
Self-managemeprogrammes selected shouldemphasis on 8 elements: (a) seefficacy building; (b) selfmonitoring; (c) goal-setting andaction-planning(d) decision-making; (e) problem-solving; (f) self-tailoring; (g) partnership between the vieof patients and health professionals; and (h) community-based and closehome. The trials in whiinterventions primarily focuseon managing paand minimizingdisability were qualified for inclusion
e
Main positivereported
(CBT) or standversus self-mo
ent
d lay
elf-
f-
d ;
ews
e to
ich
ed ain
Results of metfavour of self-mcompared with Self-efficacy(i) Arthritis-relaSignificant redat 4 months fro(SMD= -0.23, 9to -0.1, p=0.00months from 3-0.29, 95% CI:p=0.0003), at 1from 3 RCTs (S95% CI: -0.23 p=0.008) usinganalogue scalenumeric scale. (ii) arthritis-relaSignificant reddisability at 12 RCTs(SMD= -0.27 to -0.07, p (iii) Chronic baintensity None of the 3 sshowed significeffect in reduc (iv) Disability a
Results
e results from outcomes
Ovcon
dard CBT onitoring control
ta-analyses in management h control were
ated pain uction in pain om 7 RCTs 95% CI: -0.36
003), at 6 3 RCTs (SMD=
-0.41 to -0.17, 12 months SMD= -0.14, to -0.04,
g visual e and visual .
ated disability uction in months from 3 0.17, 95% CI: -p=0.0006).
ack pain
studies cant positive ing back pain.
associated with
Thiselfproa bpaichrconfor meselfproto mredyeaneemabac
erall study nclusion
s study shows that f-management
ograms probably have eneficial effect on n and disability for
ronic musculoskeletal nditions. Particularly arthritis, results of ta-analyses show thatf-management
ograms have a small moderate effect in ducing pain within 1 ar. Further research iseded on self-nagement for chronic
ck pain.
KCE Report 1
Abacus summ
t
There is evidenceself-management small to moderatebenefit for arthritisrelated pain and disability. Howevechronic back pain,evidence is insuffiFurther research oself-management improving and disis needed. The authors ensurthat included RCTevaluated self-management interventions that designed to give tpatient effective pmanagement stratsuch as relaxationexercise advice, medication adviceproblem solving, decision making, aplanning and self-tailoring.
192S
mary
that has
e s-
er for , the cient. on for ability
red Ts
were he ain tegies
n,
e,
action
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Duke et al. 2009 Australia
Type Adult2 diadefinAmerDiabeAsso Exclumatudiabeyounggestadiabe
92S
ent ulation usion ria)
Settin(primacare, seconcare)
2 diabetes
ts with type betes as ed by WHO, rican etes ciation.
uded rity onset
etes of the g and ational etes.
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
9 RCTs
n criteria
Type of intervention and definition
Individual patient education.
Chronic car
Description of interventions
The interventionwas individual face-to-face pateducation (not telephone or computer-basedwhile control individuals received usual care, routine treatment or groeducation. Only studies thaassessed outcomeasures at leasix months frombaseline were included. Six studies compared individual education to uscare and threecompared individual education to groeducation
e
Main positivereported
chronic back pOnly one studyshort-term (3 msignificant posimproving disasize: -2.30, 95-0.39)).
n
tient
d)
oup
at ome ast
m
ual
oup
Clinical (i) HbA1c In the six studiindividual faceeducation to usindividual educsignificantly im(WMD= -0.1%to 0.1, p=0.33)18 month periothere was a sigbenefit of indiveducation on Hsubgroup of thinvolving patiebaseline HbA18% (WMD -0.30.5 to -0.1, p=0 In the two studindividual to grthere was no sdifference HbA(WMD=0.03%to 0.1) at 12 to (II) BMI and blo
Results
e results from outcomes
Ovcon
pain y reported a months) itive effect in
ability (effect % CI:(-4.21 to
es comparing -to-face sual care, cation did not
mprove HbA1c , 95% CI: -0.3 ) over a 12 to od. However gnificant vidual HbA1c in a ree studies nts with higher c greater than
3%, 95% CI: -0.007)
dies comparing roup education, significant A1c , 95% CI: -0.02
o 18 months
ood pressure
ThisugindglyccomcarthoHbA Howdid signbeteducar In tstuandtheimpto 1Addneethe
erall study nclusion
s systematic review ggests a benefit of ividual education on caemic control when mpared with usual re in a subgroup of ose with a baseline A1c greater than 8%.
wever, overall there not appear to be a
nificant difference tween individual ucation and usual re.
the small number of dies comparing groupd individual education,re was an equal
pact on HbA1c at 12 18 months. ditional studies are eded to delineate se findings further.
Abacus summ
p ,
There were too fewstudies as well as few outcomes repto perform a metaanalysis on the effindividual educatiodiabetes knowledgpsycho-social outcand diabetes complications or hservice utilization cost analysis in thstudies. The focus of the fiof this review wasglycaemic control than patients’ knowledge, self-efand health care utilisation so the obenefit from indivipatient education diabetes is limited
125
mary
w too orted -fect of on on ge, comes
health and ese
indings on rather
fficacy
overall dual in
d.
126
Reference (author, year, country)
Patiepopu(inclucriter
Effing et al. 2009
chronobstrpulmdisea Patieclinicof COasthmfocuson purehabstudieusuacontrwere
ent ulation usion ria)
Settin(primacare, seconcare)
nic ructive onary
ase (COPD)
ents with a cal diagnosis OPD (not ma). Studies sing mainly ulmonary bilitation and es without l care as a
rol group excluded
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
15 group comparisons drawn from 14 controlled trials (randomisedand non-randomised)
n criteria
Type of intervention and definition
)
Self-management education. The interventions were categorised into COPD education and/or self-treatment guidelines. COPD education was a programme which transfers information about COPD and treatmeof COPD in any ofthe following formswritten, verbal, visor audio. Self-treatment guidelines includedwritten plan produced for the purpose of patient self-management COPD exacerbations.
Chronic care
Description of interventions
ent f s: ual
d
of
The educationaprogrammes toothe format of groor individual education ± media/written communicationexercise sessio± follow up sessions or telephone calls.With interventiodirected towardCOPD management suas smoking cessation, improving exercnutrition, self-treatment of exacerbations, inhalation technique or coping with activities of dailyliving, or a combination of these. Self-treatment guidelines (actioplan) might info
e
Main positivereported
There was no difference in thindividual versor group educaand systolic orpressure.
al ok oup
, ± ns
. ons s
uch
cise,
y
on rm
Self-efficacy/H(i) Significantlyreduction in totSt George’s ReQuestionnaire (WMD= -2.58; -0.02) respectimanagement eusual care from Clinical (i) A small but reduction was dyspnoea meaBORG-scale (W95% CI: -0.96 (ii) No significafound in either or exercise cap Health-care u(i) Significant rprobability of ahospital admispatients receivmanagement ecompared to thusual care (OR0.47 to 0.89).
Results
e results from outcomes
Ovcon
significant he impact of us usual care ation on BMI r diastolic blood
HQoL y higher tal score on the espiratory (SGRQ) 95% CI: -5.14 to vely in self-
education vs m 7 studies.
significant detected in
asured with the WMD= -0.53; to -0.10)
ant effects were r lung function pacity
se reduction in the at least one ssion among ving self-education hose receiving R= 0.64; 95% CI
It ismais aredadminddetothparin itenorecmain CHowhetintepoptimmestillformrecregconmaproCO
erall study nclusion
s likely that self-nagement education
associated with a duction in hospital missions with no ications for trimental effects in er outcome
rameters. This would tself already be ough reason for commending self-nagement education
COPD. wever, because of terogeneity in erventions, study pulations, follow-up e, and outcome asures, data are l insufficient to mulate clear
commendations garding the form and ntents of self-nagement education
ogrammes in OPD
KCE Report 1
Abacus summ
There is need for large RCTs with aterm follow-up, bemore conclusions be drawn. Additionmany studies weredesigned to measself-efficacy so conclusions on thimeasure are limite
192S
mary
more a long-efore
can nally e not ure
is ed.
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Gibson et al. 2009 Australia
Asthm Adultyearsasthm
92S
ent ulation usion ria)
Settin(primacare, seconcare)
ma
ts over 16 s of age with ma
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
36 RCTs
n criteria
Type of intervention and definition
1.Patient educatiofor self-manageme2. self-monitoring3.regular medical review 4.written action pla Patient asthma education is a programme which transfers informatiabout asthma in anof these forms: written, verbal, visor audio. It may be interactivor non-interactive, structured or unstructured. The content of theeducation must berelated to asthma and its
Chronic car
Description of interventions
patients about when and how tadjust and/or stmedication in caof an exacerbat
n ent
an
on ny
ual
ve
e e
Patient self-management education was either minimal omaximal. Minimal educatiwas characterisby the provisionof written materalone or the conduct of a shunstructured verbal interactiobetween a healtprovider and a patient where the primary goato improve patieknowledge and understandingof asthma. Maximal educatis considered to
e
Main positivereported
to tart ase tion.
(ii) No significafound in numbexacerbations emergency de (ii) No significafound in numbfrom work
or
ion sed n rial
ort
on th
al is ent
tion o be
QoL Compared withself-managemreduced (i) quality of lifemean differenc0.11 to 0.47) (6(ii) days off wo(RR 0.79, 95%0.93) Clinical (I) Self-managreduced noctu0.67, 95% CI: (ii) Positive effeself-managemeducation on impeak expiratormeasure of lunthat achieved ssignificance at Health-care u
Results
e results from outcomes
Ovcon
ant effects were er of and partment visits
ant effects were er of days lost
h usual care, ent education
e (standard ce 0.29, 95% CI: 6 RCTs)
ork or school % CI: 0.67 to
ement education rnal asthma (RR 0.0.56 to 0.79) ect of asthma ent mprovement in ry flow (a ng function) statistical t p < 0.05
se
Eduselfinvoby flowcoumewritimpoutastTrathato ausinplaeffeformma
erall study nclusion
ucation in asthma f-management which olves self-monitoring either peak expiratoryw or symptoms, upled with regular dical review and a tten action plan proves health tcomes for adults with hma.
aining programmes t enable people
adjust their medicationng a written action n appear to be more ective than other ms of asthma self-nagement
Abacus summ
y
n
Self-managementeducation that inva written action plaself-monitoring anregular medical re(based on recommendationscurrent asthma guidelines) result improvements in sefficacy, clinical outcomes and redhealth care use inwith asthma. Interventions that not contain a writtasthma plan wereeffective.
127
mary
t olves an,
nd eview
s in
in self-
duced adults
did en not as
128
Reference (author, year, country)
Patiepopu(inclucriter
Guevara et al 2003 USA Duplicate Cochrane Wolf
Childadoleasthmto 18
ent ulation usion ria)
Settin(primacare, seconcare)
dren and escents with ma, aged 2 years
Settingreporteassumbe maprimarcare.
Inclusion
ng ary
ndary
Types and number of studies identified
g not ed
med to ajority ry
32 RCTs 15 RCTs Adolescents 13 to 18 years. 12 RCTs children 2 to 5 years
n criteria
Type of intervention and definition
management. Self-monitoring regular measurement of PEF or symptomsRegular review-consult with doctoron regular basis Written action planindividualised writtplan for the purposof self-managemeSelf-management was compared witusual care.
Educational interventions for semanagement
Chronic care
Description of interventions
r
n- ten se nt.
h
structured with tuse of both interactive and non-interactive modes of information transfer.
elf Educational programmes mowith multiple sessions and symptom basedstrategies. Educational interventions in self-managemerelated to the prevention of asthma, management ofasthma attacks development ofsocial skills. Detailed descriptions of interventions wenot reported.
e
Main positivereported
the Self-managemreduced (i) hospitalisati95% CI: 0.50 tRCTs) (ii) emergency0.82, 95% CI: RCTs) (iii) unscheduledoctor (RR 0.6to 0.81) (11 RC
ost
d
ent
f or
f
ere
Self-efficacySelf-efficacy mreported as cohealth locus ofThere was a mimprovement iwith a standardmean differenc0.36 (95% CI: p=0.0007) from Clinical A moderate imlung function. Rmeta-analysis patients) on luoutcomes tran0.24 litre increaa 9.5% increaspredicted peak
Results
e results from outcomes
Ovcon
ment education
ons (RR 0.64, o 0.82) (12
y room visits (RR 0.73 to 0.94) (20
ed visits to the 68, 95% CI: 0.56 CTs)
measures were oping scores or f control scales.
moderate n self-efficacy dised weighted ce (WMD) of 0.15 to 0.57,
m 7 RCTs.
mprovement in Results from of 4 RCTs (258 ng function slated into a ase in FEV1 and se in percentage k expiratory flow
Eduintemain cadoassto mimpeffiandan dep prothegremoprotargthe
erall study nclusion
ucational erventions for the self-nagement of asthma
children and olescents were sociated with modest moderate provement in self-cacy, lung function, d number of visits to emergency
partment.
ogrammes targeted at individual :
eatest reductions in orbidity measures, ogrammes geted at a group had greatest reduction
KCE Report 1
Abacus summ
-This systematic reand meta-analysisshowed statisticalsignificant improvements in fof most study outcMultiple sessions the greatest succeimproving self-effiand group intervenhad the greatest reduction in hospitalisations.
192S
mary
eview s ly
favour comes. had
ess at cacy ntions
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Hampson et al. 2001 U.K
Type Patietype aged(meaof dia4.9 ye
92S
ent ulation usion ria)
Settin(primacare, seconcare)
1 diabetes
ents with 1 diabetes 9–21 years
an duration abetes was ears)
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
62 studies (25 RCTs) reported in 64 publications
n criteria
Type of intervention and definition
Educational and psychosocial interventions for semanagement. Education was defined broadly to include any intervention aimedchanging diabetes-related behaviour as well those related more specifically to knowledge Psychosocial interventions are diverse and provid
Chronic car
Description of interventions
elf-
d at
as
de
Most of the studused family therapy, followeby behavioural principles and ththird largest usesocial learning theory. Minority of the studies used interventions thcould not be categorised as family therapy,behavioural therapy or socialearning theory,such as anchorinstruction or social support.
e
Main positivereported
rate. Health-care uEducational intassociated witreduction in nuan emergency WMD -0.21 (950.09, p=0.0007(1899 patients
dies
ed
he ed
at
al ed
Self-efficacy(i) Group-baseintervention imto control (usudiabetes speci(p < 0.05) (Boa1993). (ii) Patients in efficacy improvcoping skills traintensive diabemanagement, were less upse(p < 0.001), fouless hard (p < diabetes had letheir quality of compared with(intensive man
Results
e results from outcomes
Ovcon
se terventions were h a modest
umber of visits to y department 5% CI; -0.33 to -7) from 18 RCTs ).
in hprosingsesgremo thomutheimpeffiredED
ed behavioural mproved relative
al care) on fic stress levels ardway et al.
diabetes self-ved more in aining plus etes (p < 0.05), and
et with coping und coping 0.01) and ess impact on life (p < 0.04)
h control nagement only)
Edusocsmbenvarma Qunarevidinteliketheintevardia
erall study nclusion
hospitalisations. ogrammes comprising gle ssions had the eatest reductions in orbidity measures, ose comprising ltiple sessions had greatest
provement in self cacy and the greatest
duction in n visits to
ucational and psycho-cial interventions haveall to medium neficial effects on rious diabetes nagement outcomes.
antitative and rrative analysis of thedence suggested that erventions are more ely to be effective if y demonstrate the
er-relatedness of the rious aspects of betes management.
Abacus summ
t
-e
Combining both mand non-medical aspects of diabetemanagement wassuccessful for adolescents than interventions that on one aspect. The evidence in threview arise mainlstudies in the USAhence it provides starting point for thdesign of intervenfor other countries
129
mary
medical
es more
focus
his ly from A, a he tions
s
130
Reference (author, year, country)
Patiepopu(inclucriter
ent ulation usion ria)
Settin(primacare, seconcare)
Inclusion
ng ary
ndary
Types and number of studies identified
n criteria
Type of intervention and definition
training and suppoin such areas as social skills, diabetes-related problem-solving ancoping skills, communication skills, and individuand family based counselling.
Chronic care
Description of interventions
ort
nd
al
e
Main positivereported
Clinical (i) Diabetic con(combination odoctor ratings)family therapy of nine control patients improv12 months (Ry (ii) multi-familyof adolescentsdiscuss diabetshowed significHbA1c at 3 mowith no interve(p<0.05) (Satin (iii) Control (usshowed a signdecline in metaover the 18 mo(Anderson et a (iv) Self-monitoglucose traininlower HbA1 at 0.01) and at 2than control (u(Dalamater et (v) Both copingplus intensive management a(intensive manpatients had imHbA1c over tim
Results
e results from outcomes
Ovcon
ntrol of HbA1c) and ): eight of nine patients and two (usual care)
ved (p< 0.05) at yden et al. 1994).
y group therapy s and parents to es management cant decrease in onths compared ention (control) n et al. 1989).
sual care) group ificantly greater abolic control onths (p < 0.04) al. 1989).
oring of blood ng patients had a
1 year (p < years (p < 0.05) sual care) al. 1990).
g skills training diabetes and control nagement only) mproved me in both
erall study nclusion
KCE Report 1
Abacus summ
192S
mary
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Hawthorne et al. 2008 U.K
Type Ethniwith tdiabeof anduratdiagnor witcompdiabe
92S
ent ulation usion ria)
Settin(primacare, seconcare)
2 diabetes
ic minorities type 2 etes mellitus y tion of nosis, with thout plications of etes
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
11 RCTs
n criteria
Type of intervention and definition
Culturally appropriate healtheducation Culturally appropriate healtheducation is definehere as educationthat is tailored to thcultural or religiousbeliefs and linguistskills of the community being approached, takinginto account likely literacy skills
Chronic car
Description of interventions
ed
he s tic
g
s
Culturally appropriate heaeducation couldinclude adaptingestablished heaeducation to innovative delivmethods, suchas using community basehealth advocateor delivering it tsame gender groups, or adapdietary advice toin with the likelydiet of a particucommunity
e
Main positivereported
groups (p < 0.0for IG1 (p < 0.01998).
Health-care u(i) Individual-bamay be more cstaff involvemebased intervenpermit a more approach that individual’s pawhich may be effective in the
alth d g
alth
very
ed es, o
pting o fit y lar
Self-efficacy(i) Knowledge in the interventmonths, 4 RCT95% CI: 0.4 to 5 RCTs (SMD to 0.7) and tweRCTs (SMD 0.to 0.6) post intfrom 10 RCTs(ii) no significacompared within patient-base(quality of life mattitude scoresof patient empself-efficacy) Clinical (i) Glycaemic cshowed an impfollowing cultu
Results
e results from outcomes
Ovcon
001) but more so 04) (Grey et al.
se ased education costly in terms of ent than group-ntions, but they targeted meets the rticular needs, more cost-
e long term.
scores improved tion groups at 3 Ts (SMD 0.6, 0.7), six months 0.5, 95% CI: 0.3
elve months 2 .4, 95% CI: 0.1 ervention results
ant improvement h control groups ed outcomes measures, s and measures owerment and
control (HbA1c), provement rally appropriate
Culdiaeduhavon knoNonlonclintermbe
erall study nclusion
lturally appropriate betes health ucation appears to ve short term effects glycaemic control and
owledge of diabetes. ne of the studies wereg-term, and so
nically important long-m outcomes could notstudied
Abacus summ
d
e
t
Only two RCTs measured patient empowerment andefficacy outcomesfound no significandifferences betweintervention and cgroups. There is a need foterm RCTs that compare different and intensities of culturally approprihealth education wdefined ethnic mingroups
131
mary
d self-s and nt en
control
or long-
types
ate within nority
132
Reference (author, year, country)
Patiepopu(inclucriter
Jones et al. 2011 U.K
Strok Post-patie Meanrangeto 78
ent ulation usion ria)
Settin(primacare, seconcare)
ke
-stroke nts
n age ed from 55 years
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
22 studies intotal. 19 single-arm studies, many community sample of <100 stroke patients, 2 RCTs and I non RCT
n criteria
Type of intervention and definition
n Self-efficacy and self-management Self-efficacy is defined as `peoplebeliefs about their capabilities to produce designatelevels of performance that exercise influence over events that affect their lives'.
Chronic care
Description of interventions
e's
ed
Self-efficacy ansocial cognitiontheory as basis self-managemeprogrammes forpost-stroke patients.
e
Main positivereported
health educatio(WMD - 0.3%, -0.01), and at s(WMD -0.6%, 90.4), comparedgroups who recare’. This effesignificant at 1intervention (WCI: -0.4 to 0.2)(ii) no significacompared within lipid levels apressure
d of
ent r
Self-efficacyThere is evideefficacy is an ivariable assocvarious outcomincluding qualiperceived headepression, ADcertain extent, functioning. Evidence from(Johnson 2007manual-based designed to incperceived contshowed significrecovery from compared to acontrol group. A small non RC
Results
e results from outcomes
Ovcon
on at 3 months 95% CI: -0.6 to
six months 95% CI: -0.9 to -d with control ceived ’usual
ect was not 2 months post
WMD -0.1%, 95% ) ant improvement h control groups and blood
nce that self-mportant
ciated with mes post-stroke ty of life or lth status, DL and, to a physical
one RCT 7) evaluating a
intervention crease trol ( n=203) cantly better disability
a decline in
CT (Huijbregts
TherestogstaandthamaconconstroThirednegof sredand
erall study nclusion
ere is a need for earchers, to work ether with other keholders to develop d test interventions t can support self-nagement skills and
nfidence to make ntinued progress after oke. s could help to
duce some of the gative consequences stroke such as duced quality of life d social isolation
KCE Report 1
Abacus summ
Further research oself-management programmes that self-efficacy as anunderlying construneeded. The majority of evfrom this review isbased on small sinarm studies makindifficult to assess effectiveness of anintervention as thewas no control comparison. FurthRCTs evaluating sefficacy interventiostroke patients arerequired to determwhat is effective inpatient group.
192S
mary
on
utilise n uct is
vidence s ngle ng it the n ere
her self-ons in e
mine n this
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Jovicic et al. 2006 Canada
Heart patieof agor oldwere with h
92S
ent ulation usion ria)
Settin(primacare, seconcare)
t failure
nts 18 years e
der who diagnosed
heart failure
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
6 RCTs
n criteria
Type of intervention and definition
Self-management Self-management was defined as "decisions and actions taken by someone who is facing a health problem or issue inorder to cope with and improve his or her health.”
Chronic car
Description of interventions
n it
Self-managemeinterventions included programmes aimat enabling patients to assuresponsibility fomanaging one omore aspects oheart failure (e.gsymptom monitoring, weight monitorinmedication dosaadjustment anddecision-makingGroup or individeducation sessiwith home visit phone call followups. One RCT (Ross) used an educational software with messaging communication between patientand staff.
e
Main positivereported
2008) (n=30) sweekly 6 weekintervention, shparticipant grosignificantly onbalance scale independence
ent
med
ume or or f g.
ng, age /or g). dual ions or w
ts
Self-efficacyOne study (Kothat patients ingroup were siglikely to have aperform daily wmonitor symptoand not smoke(Ross) reporteimprovement igeneral medicaof self-manageadherence to pmedical advicethere was no sdifference in fucapabilities, syand quality of l Clinical The effect of son mortality wa(OR = 0.93; 951.51) Health-care u(i) Self-manage
Results
e results from outcomes
Ovcon
studying a twice k group based howed the up improved
n living index, and functional scale.
oelling) showed n the intervention gnificantly more an action plan, weighing, oms, exercise e. Another RCT ed a significant n adherence to al advice. Effect ement on prescribed e improved, but significant unctional ymptom status life
elf-management as not significant 5% CI 0.57 to
se ement
Selpropatdecreareafailu Resstuthamainteintecomlike
erall study nclusion
lf-management ograms targeted for tients with heart failurecrease overall hospitaadmissions and admissions for heart ure.
sults from individual dies seem to indicate t the self-nagement
erventions with more ensive education mponents are more ely to show benefits
Abacus summ
e l
Future research isneeded to assess whether improvements in mortality and quallife can be achieveself-management The pooled results3 RCTs showed asignificant reductiohospital readmissidue to heart failureResults from otheoutcomes such asmortality and QoLless conclusive baon results from theout of six RCTs threported these outcomes.
133
mary
s
ity of ed with
s from a on in ions e. r
s were
ased e three
hat
134
Reference (author, year, country)
Patiepopu(inclucriter
Korpershoek et al. 2011 The Netherlands
Strok Adultstrokphasstrok
ent ulation usion ria)
Settin(primacare, seconcare)
ke
ts with e in all es after e
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
17publications 4 RCTs butmajority cross-sectional studies with < 100 patients
n criteria
Type of intervention and definition
Self-efficacy The concept self-efficacy is describeas the confidence one’s ability to perform a task or specific behaviourhigh sense of self-efficacy leads desired outcomes,such as improvedhealth.
Chronic care
Description of interventions
ed in
r. A
to ,
Self-efficacy included situatioand task-relatedbehaviour specconcept. The strongest way oinfluencing self-efficacy was mastery experience through succesperformance of task
e
Main positivereported
decreased all-creadmissions (CI: 0.44 to 0.80failure readmis95% CI: 0.27 t(ii) Self-managfailure on repofrom reduced rutilization rangto $7515 per p
on- d, ific
of -
sful a
Self-efficacySelf-efficacy wassociated witdaily living as schronic model management c(Kendall 2007)showed positivcare as measuself-efficacy scsocial roles (p<productivity (p< Four self-efficainterventions wbut the evidencinterventions w Clinical Self-efficacy wassociated witquality of life aassociated wit
Results
e results from outcomes
Ovcon
cause hospital (OR 0.59; 95% 0) and heart ssions (OR 0.44; o 0.71).
gement of heart orted savings resource ged from $1300 patient per year
was positively h activities of shown by a self-
course in a RCT ) (n=110) ve effect of self-ured by the QOL cale: (p<0.001), <0.001), work <0.001) .
acy enhancing were identified ce of these
was inconclusive.
was positively h mobility,
and negatively h depression
PateffibetthaselfThecondetinfluandintecleacanselfinteclinpeo
erall study nclusion
tients with high self-cacy are functioning tter in daily activities n patients with low f-efficacy. e evidence ncerning the terminants uencing self-efficacy d the self-efficacy erventions makes ar how nurses n develop and tailor f-efficacy erventions for the nical practice of ople with stroke
KCE Report 1
Abacus summ
This review was liby a lack of RCT evidence. Positivefindings on self-effoutcomes were demonstrated by oRCT. Overall, the variety of study deinclusion criteria ainstruments used it impossible to pofindings.
192S
mary
mited
e fficacy
one
esigns, and made
ool the
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Mason et al 2008 UK
Chrodisea Patieof thestagekidneearlydialysdialysMeanyearsKidnetransrecipexclubecagroupadditeducneedbeyoscopereview
McGillion et al. 2004 Canada
chronangin CSA expeclassanginto the
92S
ent ulation usion ria)
Settin(primacare, seconcare)
nic kidney ase (CKD)
ents in any e following es of chronic ey disease: , pre-sis, and sis. n age 55 s. ey plant ients were
uded use this p has ional ational s that are nd the e of this w
Primarseconand te
nic stable na (CSA)
outpatients riencing
s I, II or III na according e Canadian
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
22 RCTs Sample sizes ranging from10 to 335 participants.
ry, dary
ertiary
4 RCTs
n criteria
Type of intervention and definition
m
Patient education Educational interventions for people with a chronic disease typically incorporainformational components to improve knowledgalong with a varietof psychological methods to empowpatients and changbehaviour.
Psycho-educationa Psycho-educationainterventions are educational treatment programmes featuring multi-mo
Chronic car
Description of interventions
te
e, ty
wer ge
Interventions involved components aimat improving boknowledge and motivation. Thecomponents weused in various combinations anformats rangingterms of complexity. Most studies usan individual ratthan a group format to delivethe interventionand all interventions toplace in hospita
al
al
dal
One study usedstress management training for angisymptoms and medication useAnother focusseon the impact o
e
Main positivereported
med th
se ere
nd g in
sed ther
r ,
ok als.
Self-efficacyResults from 4indicated signiimprovements knowledge retedialysis care Clinical (i) One study wthat involved 7an estimated gfiltration rate lemL/min/1.73 mmL/s/1.73 m2)period in pre-d(ii) Results frompre-dialysis ca20 years, theresignificant incrrates. Health-care uResults from 4dialysis care insignificant implong-term deladialysis therap
d
ina
. ed f
Self-efficacy(i) Patients in tsmall group sestress managerelaxation techreported being(p<0.001), less(p<0.05), and h
Results
e results from outcomes
Ovcon
4 studies ficant in long-term
ention in pre-
was identified 70 patients with glomerular ess than 30 m2 (<0.5 ) during a 4-week dialysis care m 4 studies in
are indicated at e were reases in survival
se 4 studies in pre-ndicated rovements in
ayed onset of py
MustruinteeffeandquawasEffedevevaintereqthowithchrThiposdelkidn
three biweekly essions on ement and hniques g more relaxed s stressed having fewer
Althshoeffewithsymsymdistfun
erall study nclusion
lticomponent uctured educational erventions were ective in pre-dialysis d dialysis care, but theality of many studies s suboptimal. ective frameworks to velop, implement, andaluate educational erventions are quired, especially ose that target patientsh early stages of ronic kidney disease. s could lead to
ssible prevention or ay in progression of ney disease.
hough these trials owed some positive ects for CSA patients h respect to angina mptoms, angina mptom-related tress and physical ctioning,
Abacus summ
e
s
This review showeneed for better deRCTs evaluating sefficacy interventiochronic kidney disThe included studthis review lackedrigorous study desand consistency between interventterms of theories amethods used andthey are delivered
There were some positive findings frthe included studiethe intervention ofpsycho-educationinterventions in CSresulting in fewer episodes, angina
135
mary
ed the signed self-ons in
sease. ies in a sign
tions in and d how
d.
rom es with f al SA angina
136
Reference (author, year, country)
Patiepopu(inclucriter
CardSocieclasssysteangin
Monninkhof et al. 2003 Netherlands
chronobstrpulmdiseaexclustudiepatie
ent ulation usion ria)
Settin(primacare, seconcare)
iovascular ety sification em for rating na severity
nic ructive onary
ase (COPD), uding es with nts
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
12 studies (8 RCTs)
n criteria
Type of intervention and definition
self-help treatmenpackages; employing both information-based material and cognitive-behavioural strategies
Self-management education COPD education was defined as a programme which transfers informati
Chronic care
Description of interventions
t three biweekly small group stremanagement anrelaxation session chest pain discomfort and stress. A third focussed on group/individuarehabilitation programme, andthe fourth evaluated effectof a 3-week smgroup stress management anrelaxation programme.
on
Included studiesfocussed on groor individual education with/without thefollowing; patienbrochure, actionplan, smoking
e
Main positivereported
ess nd ions
l
d
ts all
nd
angina episodecompared withmonths (Gallac1997). Clinical (i) Group progrstress and lifesmanagement rangina attacksduration than cweeks (p<0.051994). (ii) Combined gindividual rehaprogramme resimproved scorefrequency (p<0severity (p<0.0and the use of nitrates (p<0.0with controls amonths (Lewin(iii) Three-weeangina managprogramme imfor depressionfrequency at 6 (p<0.01) compor usual care (
s oup
e nt n
Meta-analysis management ecompared withindicated the fo Clinical (i) St. George’s
Results
e results from outcomes
Ovcon
es (p=0.017) h controls at 6 cher et al.
ramme on style resulted in s of shorter controls at 8 5) (Bundy et al.
group and abilitation sulted in es for 0.001) and 05) of angina, f short acting 001) compared after 4–12 n et al. 1995). ek small group ement
mproved scores and angina months
pared to control (Payne 1994).
merelaconandpregen Futedureqrobredenhgenfindma
of self-education h usual care ollowing;
s Respiratory
Insobtrecbecvarmeothgen
erall study nclusion
thodological problemsated to experimental ntrols, interventions, d measurement ecluded neralisation.
ture RCTs of psycho-ucational programmesquire methodologically bust methods to duce biases and to hance the neralizability of dings for CSA nagement.
ufficient data were tained to make commendations cause of the wide riation in outcome asures used and er limitations to
neralisations in the
KCE Report 1
Abacus summ
s
s
attacks of shorter duration, and patiehaving more relaxand less stressedHowever, these rehave to be interprewith caution givensmall number of Rthe small number patients included ithe trials and a lacpooled common ebecause of heterogeneity prevany meta-analysis
Self-managementeducation reducedneed for rescue medication and leincreased use of courses of oral steand antibiotics for respiratory sympto
192S
mary
ents xation . esults eted
n the RCTs,
of in 3 of ck of effect
vented s.
t d the
d to
eroids
oms.
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
havinas thdiagn
92S
ent ulation usion ria)
Settin(primacare, seconcare)
ng asthma e primary
nosis
Inclusion
ng ary
ndary
Types and number of studies identified
n criteria
Type of intervention and definition
about COPD and treatment of COPDin written, verbal, visual, or audio forms.
Chronic car
Description of interventions
D cessation, audiotape, exercise, and nutrition .
e
Main positivereported
Questionnaire indicated betterelated quality (HRQoL); WMCI: –18.5 to –2 (ii) Percentagewho used oral showed increa1.39 (95% CI: Health-care u(i) Number of pone or more adshowed reduct(95% CI 0.43 t
(ii) Number of visits per year reduction, WM(95% CI –0.75
Results
e results from outcomes
Ovcon
(SGRQ) er health-of life D = –10 (95%
2.0).
e of patients steroids
ased use; RR 1.02 to 1.91).
se patients with dmissions tion; RR 0.80 to 1.50)
emergency showed
MD = –0.36 5 to 0.03)
curliterresnee
erall study nclusion
rrent published rature. Further earch in this area is
eded.
Abacus summ
However various smanagement educprogrammes fromeducation to indivieducation were invmaking it difficult tgeneralise the res This review is simthe Cochrane reviEffing et al. 2007.
137
mary
self-cation group idual volved to sults.
ilar to ew by
138
Reference (author, year, country)
Patiepopu(inclucriter
Niedermann et al 2004
Rheuarthri
ent ulation usion ria)
Settin(primacare, seconcare)
umatoid itis (RA)
Not reporte
Inclusion
ng ary
ndary
Types and number of studies identified
ed 11 RCTs
n criteria
Type of intervention and definition
Educational or psycho-educationainterventions Any combination olearning experiencdesigned to facilitavoluntary adoptionbehaviour conducito health (Green 1978)
Chronic care
Description of interventions
al
of ces ate n of ive
Seven RCTs provided classiceducation to teaknowledge and specifically needed skills , whereas 4 studoffered cognitivbehavioural therapy with focon coping strategies and psychological support. Only 1 study, testing theffects of mailededucational leaflets, was noorganised as grtherapy
e
Main positivereported
c ach
ies e-
cus
he d
ot roup
Self –efficacy(i) improve knoIn seven RCTssignificant imppatients’ knowits managemeal 1995; HammHelliwell et al 11993; LindrothBarlow et al 191998; Scholter (ii) Coping Out of 6 studiecoping, only 3 significant imp(Kraaimaat et aet al 1995; Par (iii) complianceOut of 6 studiecompliance, 5 significant impet al 1998; Ham1999; Taal et aet al 1997; Sch1999). Clinical All RCTs exceal 1993) evaluapsychological including depreanxiety. Two ssignificant imp
Results
e results from outcomes
Ovcon
y owledge: s, there was rovement in
wledge of RA and nt (Kraaimaat et
mond et al 1999; 1999; Taal et al et al 1997;
997; Barlow et al rn et al 1999).
es that examined reported rovements al 1995; Parker rker et al 1988).
e es that evaluated reported rovements (Brus mmond et al al 1993; Lindroth holtern et al
pt one (Taal et ated health status ession and
studies showed rovements in
MedesmodemoutShoprogenwhechaaredemneestratheeffehea
erall study nclusion
thodologically better-signed studies had
ore difficulties monstrating positive tcome results. ort-term effects in
ogram targets are nerally observed, ereas long-term anges in health status e not convincingly monstrated. There is aed to find better ategies to enhance transfer of short-term
ects into gains in alth status.
KCE Report 1
Abacus summ
a
m
No clear conclusiothe effectiveness oeducational or psyeducational interventions can made from this revas many of the stuoutcomes were podefined and studyeffects were not measured long-terOverall, judging froevidence presentethis review, self-management withpsychological component in addpurely education programmes appebe more beneficiaimproving knowledcoping, compliancpsychological hea
192S
mary
ons on of ycho-
be view udy oorly y
rm. om the ed in
a
dition to
ears to al in dge, ce, and alth.
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Powell et al. 2003 Australia
Asthm Predoadultyearsasthmby dodiagnobjecor acAmerThoraguide
92S
ent ulation usion ria)
Settin(primacare, seconcare)
ma in
ominantly s (>16 s old) with ma (defined octor’s nosis or ctive criteria ccording to rican acic Society elines.
Primarseconand te
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
15 RCTs describing 26 interventions
n criteria
Type of intervention and definition
Self-management education Self-management education is considered to be necessary “to helppatients gain the motivation, skills aconfidence to conttheir asthma.
Chronic car
Description of interventions
p
and trol
Six studies compared optimself-managemeallowing self-adjustment of medications according to anindividualised written action plto adjustment omedications by doctor. Three studies compared self-management options. One thaprovided optimatherapy but testthe omission of regular review. Another compahigh and low intensity educatIn a third, no difference in hecare utilisation olung function wareported betweeverbal instructioand written actioplans.
e
Main positivereported
depressive diset al 1997; Sch1999), and oneimprovements (Bradley et al 1
mal ent
lan f a
at al ted
red
tion.
alth or as en on on
Clinical Pooled resultswhich reportedforced flow (PEsignificantly favpeak flow self-over medicatiovia regular me(SMD=0.16, 950.31) from 3 R
Results
e results from outcomes
Ovcon
sorders (Barlow holtern et al e significant in anxiety
19987)
of three studies d peak expiratory EF) data voured optimal -management ons adjustment dical review 5% CI: 0.01 to
RCTs.
Optmafor astadjmeconadjof aor brevwritbasequplasym
erall study nclusion
timal self-nagement allowing optimisation of hma control by ustment of dications may be
nducted by either self-ustment with the aid a written action plan by regular medical
view. Individualised tten action plans sed on PEF are uivalent to action ns based on
mptoms.
Abacus summ
-
This review focussclinical outcomes.PEF data significafavoured optimal pflow self-managemover medications adjustment via regmedical review. That is interventioinclude a written aplan were more efficacious. Due to the small nof trials in each subgroup analysisthe way in which dwere reported thewere few studies tcould provide datameta-analyses.
139
mary
sed on The
antly peak ment
gular
ns that action
number
s and data re that a for
140
Reference (author, year, country)
Patiepopu(inclucriter
Riemsma et al. 2003 Multinational
rheumarthri Adultagedwith cconfirthe dRA.
Saksena 2010
≥ 18 diagnhealtprofehavinhype
ent ulation usion ria)
Settin(primacare, seconcare)
matoid itis (RA)
t patients >18 years clinical rmation of iagnosis of
Primarseconand te
years nosed by a hcare
essional as ng rtension
Not reporte
Inclusion
ng ary
ndary
Types and number of studies identified
ry, dary
ertiary
50 studies from 47 trials (31 RCTs with relevant data were included)
ed 4 RCTs and 1 non-RCT
n criteria
Type of intervention and definition
Patient education Patient education intervention was defined as one thaincludes formal structured instruction rheumatoid arthritis and on wato manage arthritissymptoms
Computer-based education Interventions havebe computer baseComputers have tobe used by patientwith hypertension
Chronic care
Description of interventions
at
ion
ays s
Patient educatioin the review focussed on teaching patientto adjust their dactivities as dictated daily bydisease symptoIt included elements of information onlycounselling, andbehavioural treatment
e to d o ts
Interactive computer learnitool Standard education plus computer programme
e
Main positivereported
on
ts aily
y oms.
y, d
Self-efficacy(a) At first follosignificant effeeducation for sdisability (SMDCI: -0.25, -0.09(ii) joint counts95% CI: -0.24,(iii) pain: (SMD-0.16, 0.00). (b) At final follosignificant effeeducation were Clinical a) At first followsignificant effeeducation for s(i) patient glob(SMD = -0.28, 0.07) (ii) psychologic-0.15, 95%CI: (iii)depression 95% CI: -0.23,
ing Several intervedemonstrated components ofcould be influecomputer-baseinterventions.Self-efficacyTwo studies mchanges in sel
Results
e results from outcomes
Ovcon
ow-up there were ects of patient scores on (i) D = -0.17, 95% 9) s (SMD = -0.13, -0.01),
D= 0.08, 95% CI:
ow up no ects of patient e found.
w-up there were ects of patient scores on al assessment 95% CI: -0.49, -
cal status (SMD= -0.27, -0.04) (SMD = -0.14, -0.05)
PatprorevshodisapatasspsydepTheof laduarth
entions that different f the HBM
enced through ed
measured f-efficacy and
Noncominteto din hitseshointeusepro
erall study nclusion
tient education as ovided in the studies viewed had small ort-term effects on ability, joint counts, tient global sessment, ychological status andpression. ere was no evidence ong-term benefits in ults with rheumatoid hritis.
ne of the studied mputer-based erventions were able demonstrate a changehealth behaviours by elf , but this research ows that these erventions must be ed in concert with ovider-based health
KCE Report 1
Abacus summ
Significant effects patient education follow-up for scoredisability, joint coupatient global assessment, psychological statand depression. Patient education review was providaddition to standamedical care so theffects of patient education as supplementary to benefits of standamedical care musttaken into account
e
No direct effect onhealth behaviour cbe demonstrated. results nevertheleindicate that compbased education mhave the potentialplay an important self-management subjects with
192S
mary
of at first
es on unts,
tus,
in the ded in rd
he
the rd t be t.
n could The ss
puter-may to role in of
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Smith et al 2007
Sevedifficu
92S
ent ulation usion ria)
Settin(primacare, seconcare)
ere or ult asthma
Seconor terticare, researfacility
Inclusion
ng ary
ndary
Types and number of studies identified
ndary iary
rch y.
13 RCTs, 4 controlled observational studies
n criteria
Type of intervention and definition
The intent of the programme is to educate patients about their chronicdisease.
Psycho-educationainterventions Interventions deemed to be a psycho-education the basis that a major component it (i) involved interaction betweepatient and provide(ii) involved taking an educational, cognitive, behavioural, and/o
Chronic car
Description of interventions
c
Pamphlet, websregistration andorientation, accto different utilitplus home bloopressure monitoring Internet-based chronic diseaseself-managemeprogramme Online internet community withnew informationposted weekly aemail newslette
al
on
of
en er
or
All studies evaluated a singpsycho-educatioprogram of whicthree were classified as educational, fouas self-management, three as psychosocial, and seveas multi-faceted
e
Main positivereported
site d ess ies d
e ent
h n and
er
self-care behanon randomisethat used an ocommunity (Yu8.7% improvemefficacy compain controls , p=Clinical One study shocombining a weducational intpharmacist carimprove BP cop<0.001).
gle onal ch
ur
o-en d .
Self-efficacyNR Clinical (i) Asthma-spePsycho-educainterventions hsignificant effespecific QoL (SCI: -0.07 to 0.9sensitivity anasignificant effe95% CI: 0.00 t Health-care u(i) Accident an
Results
e results from outcomes
Ovcon
viours. One ed control trial nline internet u) found a ment in self-ared with -1.5% =0.027.
owed that web-based tervention with re could
ontrol(
educreheaordof cintereaprofullygendel
ecific QoL tional
had non-ect on asthma-SMD=0.45, 95% 98), but lysis indicated
ects (SMD=0.36, o 0.72)
se d emergency (A
Thefurtanycarcan
erall study nclusion
ucation in order to ate lasting changes in
alth behaviours. In der for the full benefits computer-based erventions to be alized, these ogrammes must be y integrated into neral healthcare ivery.
ere is a need for ther research before y changes to standardre in this patient groupn be recommended.
Abacus summ
n hypertension.
d p
Positive effects admissions and Qafter sensitivity anwere only short-teand did not includmost at-risk patienoutliers.
141
mary
QoL nalysis erm e the nts or
142
Reference (author, year, country)
Patiepopu(inclucriter
Sarkisian et al. 2003 USA
Diabe OlderyearsAmerLatinwith dmellit
Shin et al. 2010 USA
Osteo(OA) Adultyears
ent ulation usion ria)
Settin(primacare, seconcare)
etes Mellitus
r (>55 s) African rican and o adults diabetes tus
Primarand secon
oarthritis
ts aged ≥65 s with OA
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
12 studies (8 RCTs, 4 pre/post interventions)
ry
dary
12 studies (rated as level A: high-quality RCT)
n criteria
Type of intervention and definition
social approach (iii) addressed educational, cognitive and/or social issues affecting asthma obeing a consequence of asthma
Self-management education Self-management education programmes aimeto improve knowledge and, tovariable degree, improve biophysicmarkers of health (e.g. weight and glycaemic control)and psychosocial markers of health (e.g. self-reported quality of life)
Psychosocially focused non-pharmacologic therapies (NPT) (includes patient education, self-management, copskills, and social
Chronic care
Description of interventions
or
d
o a
al
)
Interventions in review includededucational grosessions led byphysician or nuror dietician with/without weesupport groups,and exercise sessions. Elemeof self-management included behavioriented, culturatailored, one to counselling, grocounselling, supervised exercise and fainvolvement.
ing
Nine out of the RCTs used education and smanagement astheir interventiowhilst 3 providecomprehensive interventions us
e
Main positivereported
& E) admissionPsycho-educainterventions hsignificant effeadmissions (R0.55 to 1.14), banalysis indicaeffects (RR=0.0.56 to 0.99)
the d up
y a rse
ekly ,
ents
iour ally-one
oup
mily
Self-efficacyImproved QoLthe interventio(Gideon et al 1 Clinical (i) Of the 8 RCsignificant impglycaemic conintervention cocontrol arm (Ag1997; FalkenbJaber et al 199al 1986 Brown
12
self-s ns,
ed
sing
Self-efficacy(i) Four RCTs significant impefficacy (Busze2006,Hughes e2006; Keefe etused different
Results
e results from outcomes
Ovcon
ns tional
had non-ect on A & E R=0.79, 95% CI: but sensitivity ated significant 75, 95% CI:
was reported in n arm of I study
1992).
CTs, 5 reported rovements in trol in the
ompared with gurs-Collins et al erg et al 1986;
96; Mazzuca et et al 1995).
Lardescultspeandwithneehowgropro
showed rovement in self-ewicz et al 2004 and t al 2004), all measures.
AlthstuthepsyNPthe Hig
erall study nclusion
rge-scale clinical trialssigned according to tural and age criteria ecific for older Latinos d African Americans h diabetes are eded to determine w best to address this owing public health oblem
hough most of the dies demonstrated positive effects of
ychosocially focused Ts for OA patients, evidence is modest.
gh-quality RCTs which
KCE Report 1
Abacus summ
s Improved glycaemcontrol was report5 out of 8 RCTs, although attrition wproblem in most ostudies. Large-scale clinicaare needed to dethow best to manadiabetes in ethnic minorities. Studies on older Caucasians were included, as were studies on mixed-aLatino and AfricanAmerican populati
h
Results reported wqualitative makingdifficult to measureoutcome effect. Psychosocially focNPT may improveexercise, physicalfunction and decre
192S
mary
mic ted in
was a of the
al trials ermine ge
also
age n ions.
were g it e the
cused e pain, ease
KCE Reports 19
Reference (author, year, country)
Patiepopu(inclucriter
Thomas et al. 2006 UK
multip(MS) Peopdiagn(e.g. recogcriterPoseSchu1965
92S
ent ulation usion ria)
Settin(primacare, seconcare)
ple sclerosis
ple with a nosis of MS using
gnised ria such as er 1983, umacher ).
Primarand secon
Inclusion
ng ary
ndary
Types and number of studies identified
ry
dary
16 RCTs in 17 trials
n criteria
Type of intervention and definition
support) Education about self-management and coping skills cincrease patients’ knowledge, efficienself-management behaviours, self-efficacy, adherencto therapies, healthstatus, and qualitylife
Psychological interventions Psychological interventions werebroadly defined anincluded those thaaddress mood andthose that addresscognition. Cognitivfactors are those relating to the menprocesses of
Chronic car
Description of interventions
can
nt
ce h
y of
all four psycho-socially focusedNPTs (educatioself-managemecoping skills, ansocial support) fparticipants andtheir spouses
e nd at d s ve
ntal
Interventions in review were delivered by psychologists, counsellors, medical staff, nurses, occupational therapists or othhealth professionals, aincluded elemenof behavioural therapy or
e
Main positivereported
d on, ent, nd for
d
(ii) Two studiessignificant incrof exercise perdecrease in sti2004 and 2006 (iv) One study significant impobjective peak(Murphy et al. performance o(Yip et al 2007function (Keefeand pain copin2004) Clinical (i) Four studiessignificant decrease/impr(Hughes et al 2Yip 2007 and 2
the
her
and nts
Clinical (i) One RCT resignificantly beimprovement ihealth subscalcognitive rehabthan the place(mean ± SD) =9% ±41%) resp=0.04) (Solar (ii) One RCT rethe group rece
Results
e results from outcomes
Ovcon
s reported rease in minutes r week and iffness (Hughes 6)
each reported rovement in
k physical activity 2008),
of daily activities 7), physical e et al 2004), ng (Keefe et al
s reported
rovement in pain 2004 and 2006; 2008)
exapsyNPfew SpotheresprosupandpattheandmaTo fewthespo
eported etter n the mental e in the bilitation group bo group
= 27% ±73% vs pectively, ri et al 2004).
eported that eiving psycho-
No canrevreathabeharetreaandadjhav
erall study nclusion
amined the effects of ychosocially focused Ts only are relatively
w in number.
ouses can be one of most beneficial ources for patients by
oviding emotional pport d encouraging tients to cope with ir symptoms
d maintain self-nagement strategies. date, however, only a
w studies examined potential benefit of
ouses involved
definite conclusions n be made from this view. However there isasonable evidence t cognitive
havioural approaches e beneficial in the atment of depression, d in helping people ust to, and cope with, ving MS.
Abacus summ
y
a
stiffness in patientlower-extremity OA(knee and hip OA)short term. No evidence of Psychosocially focNPT in the long te
s
It is difficult to drawany firm conclusiothe effectiveness ocognitive behaviouapproaches in treaMS. There may besome positive effedecreasing depresthrough cognitive behavioural therappsychotherapy. Thwas a lot of variatiintervention types outcomes reported
143
mary
ts with A ) in the
cused erm.
wn ons for of ural ating e ect on ssion
py and here ion in and
d
144
Reference (author, year, country)
Patiepopu(inclucriter
3.5.3. QualityThe SIGN RCT
and the grading
item
Research question
randomisation
ent ulation usion ria)
Settin(primacare, seconcare)
y appraisal for inT quality appraisa
g system agreed b
Well cover
Question cl
n Method ofcomputer g
Inclusion
ng ary
ndary
Types and number of studies identified
ncluded RCTs l tool was used b
by the research te
red
lear and well expl
f randomisation generated from a r
n criteria
Type of intervention and definition
memory, concentration, reasoning and judgement
by the research te
eam.
ained
robust such asremote site
Chronic care
Description of interventions
cognitive therapor educational, counselling or rehabilitation orfamily therapy oany combinationthese.
eam to assess the
Adequately a
Question clea
s Randomisatio
e
Main positivereported
py
r or n of
therapy scoredlower on the descore than the (mean score 1respectively, p(Crawford et a (iii) One RCT (showed mean was significantcognitive behaversus minimatherapy (mean21.6 ±14.2 resstandardised mdifference = 0.0.02, 1.33).
e risk of bias of th
addressed
r
on method adequa
Results
e results from outcomes
Ovcon
d significantly epression placebo group 9.3 vs 23.5
p<0.05 ) l 1985).
(Foley 1987) depression tly lower in
avioural therapy al psycho-n 13.2 ±10.5 vs spectively, mean 66 (95%CI; -
he study. The leg
ate
erall study nclusion
gend below explai
Poorly addres
Research aim n
Poor randomsuch as alterna
KCE Report 1
Abacus summ
making interpretatthe results difficult
ns the quality ma
ssed
not clearly stated
misation methodate patients
192S
mary
tion of t.
arkers
ology
KCE Reports 19
Allocation concealment
Patient grocomparable
Dropouts aintervals described?
Analyses conducted in population?
Not addressed (i.Not reported (i.e.Not applicable.In order for RCTs
• Random• Blinding• Groups • Descript
The final column
92S
methods owith stronginvestigatormaintained
oup Study audemograph(with or wanalyses), demographdifferences to subject r
and Number ofreasons foAdditionallyof those wiclearly desc
ITT If data is shown in reappropriateanalyses, uanalysis se
.e. not mentioned, o mentioned, but ins
s to be included they
misation g comparable at basetion of dropouts in the quality appra
of concealment g likelihood of conrs and par
uthors report hics between stuithout having pe
or on inspecthics, the review
between the groesults to bias.
f withdrawals foor withdrawal cy, the point of withdrawing during cribed missing, missing
esults to have bee methods to pusing the intentiont for treatment arm
or indicates that thissufficient detail to all
y had to score a “lo
eline
aisal table is the sco
clearly describedncealment in bothrticipants being
that baselinedies were similarformed statistication of baseline
wer can see nooups that are likely
or each arm andclearly describedthdrawal for eachthe study cycle is
g data is clearlyeen imputed usingperform statistican to treat set or fums.
s aspect of study delow assessment to b
ow risk of bias” base
ore of either low = “lo
Chronic car
d h g
methods of bstudy describe
e ar al e o y
Patient demonot reported reviewer percdue to any groups studiefor a demograappropriate
d d. h s
Withdrawal narm, and reaswithdrawal du
y g al ll
Methods desprinciples, butfor the treatmshow that ITT
esign was be made)
ed on 3 of the 4 had
ow risk of of bias” o
e
blinding not cleared as single/doub
ographics in eachby authors as b
ceives there to beobserved diffe
ed. If patient grouaphic variable like
numbers are dessons, but no descring follow up or t
scribe use of int the results do noent groups or thehas not been per
d to be well covered
or high= “high risk of
rly described butble blinded
h treatment armbeing similar, bute little risk of biasrences between
ups are dissimilarely to cause bias,
scribed for eachcription of point oftreatment period.
ntention to treatot clearly state ‘n’ere is evidence torformed.
or adequately addr
f bias” based on the
t concealment participants defrom the desparticipants or participants cotreatment assig
t
r
reviewers perdifferences bdemographics,adjusted for in
f
Study does noreasons for wiarm; but for astudy as a who
t
‘As-treated’ aperformed
ressed:
e items above.
of investigators escribed but it is cription reportedinvestigators enr
ould possibly forgnments
rceives there tobetween groups which have not analyses.
ot describe numbithdrawal by treatall patients enrollole.
analysis has
145
and likely that
rolling resee
o be s in been
ber or tment ed in
been
146
Study
Appre
clefocuques
Baker 2011†
well cove
Barlow 2009
poorladdre
Berman 2009
adeqaddre
Bosworth 2009a
adeqaddr
Bosworth 2009b
adeqaddre
ropriatand
early ussed stion?
Randomisd?
red adequately addressed
ly essed
well covered
quately essed
poorly addressed
quately ressed well covere
quately essed
adequately addressed
e Observer
blinded?
Alcon
not addresse
d
not add
d Not
addressed
not add
Not addresse
d
not add
ed
adequately
addressed
adad
adequately
addressed
not add
Internal validity
location ncealmen
t?
Patiengroup
comparae?
ressed adequateaddresse
ressed adequateaddresse
ressed adequateaddresse
equately ddressed
well covered
ressed adequateaddresse
Chronic care
t p abl
Dropouts and
intervals described
?
A
cep
ely ed
well covered
ely ed
adequately addressed
ely ed
adequately addressed
d adequately addressed
ely ed
adequately addressed
e
Analyses
conducted in ITT populati
on?
Bias min
no
some differencebaseline characterfound, astatistical
yes
No dallocationconcealmblinding.through element bias
yes Study is randomisapoor – tos
yes
Good raprocess blinding researchenurses).
no No, ITT w
O
nimisation? If biasbias
significant es in
ristics were adjusted in analysis
No influe
details of
ment or Recruitment letter so
of selection
No influeinvestvoluntmay interv
not blinded, ation method ssing of coin
no blrandomethoinflueeffect
andomization and some
of ers (clinic
was not used
High followinflueinterveffect
Overall assessment
sed, how would affect results?
R
qa
blinding could nce investigators
ye
blinding could nce tigators, subjects teered for study
favour ention group
ye
inding and poor omisation odology could nce intervention t
ye
ye
drop-out rate at w-up may
nce ention/treatment
t size
ye
KCE Report 1
Research
uestion answere
d?
Risk of
es low
es low
es low
es low
es low
192S
bias
KCE Reports 19
Study
Appre
clefocuques
Bucknall 2012
adeqaddre
Cadilhac 2011
adeqaddr
Chan 2009 adeqaddr
Chen 2011 adeqaddre
Chow 2010
well cove
Copeland adeq
92S
ropriatand
early ussed stion?
Randomisd?
quately essed
Well covere
quately ressed well covere
quately ressed
poorly addressed
quately essed
adequately addressed
red adequately addressed
quately poorly
e Observer
blinded?
Alcon
ed poorly
addressed
We
ed
adequately
addressed
adad
d
not addresse
d ad
not addresse
d
adad
not addresse
d ad
not
Internal validity
location ncealmen
t?
Patiengroup
comparae?
ll covered adequateaddresse
equately ddressed
adequateaddresse
not ddressed
adequateaddresse
equately ddressed
adequateaddresse
not ddressed
adequateaddresse
not poorly
Chronic car
t p abl
Dropouts and
intervals described
?
A
cep
ely ed
adequately addressed
ely ed
well covered
ely ed
well covered
ely ed
well covered
ely ed
well covered
not y
e
Analyses
conducted in ITT populati
on?
Bias min
no
Partial researchemonthly blinded group
No, ITT uused.
yes
well condremote raand reswere ballocation
yes
blinding researchedrawing randomisawas inade
yes No blresearche
yes
No blresearcheunsure if of alloccarried ou
yes Inadequa
O
nimisation? If biasbias
blinding, er collecting
data was to patient
used was not
High followinflueinterveffect
ducted trial ; andomisation search staff blinded to group
of ers absent,
lots as ation method equate
Non-bobserrandomethoaffectsize
inding of ers
Non-binvestaffecteffect
inding of ers and concealment
cation was ut.
No influe
te
Overall assessment
sed, how would affect results?
R
qa
drop-out rate at w-up may
nce ention/treatment
t size
ye
ye
blinding of rvers and poor omisation odology could t treatment effect
ye
blinding of tigators could t intervention t
ye
blinding could nce investigators
ye
ye
Research
uestion answere
d?
Risk of
es low
es low
es low
es low
es low
es high
147
bias
148
Study
Appre
clefocuques
2010 addre
Davis 2010
adeqaddre
Ghahari 2010
adeqaddre
Hochhalter 2010
adeqaddre
Jarrett 2009
adeqaddre
Jerant 2009
adeqaddre
Kiser 2012 adeq
ropriatand
early ussed stion?
Randomisd?
essed addressed
quately essed
not reported
quately essed
adequately addressed
quately essed
well covered
quately essed
well covered
quately essed
well covered
quately well covered
e Observer
blinded?
Alcon
addressed
ad
d not
addressed
ad
not addresse
d ad
d
adequately
addressed
ad
d
adequately
addressed
adad
d not
addressed
ad
d not
Internal validity
location ncealmen
t?
Patiengroup
comparae?
ddressed addresse
not ddressed
adequateaddresse
not ddressed
adequateaddresse
poorly ddressed
well covered
equately ddressed
well covered
not ddressed
well covered
not poorly
Chronic care
t p abl
Dropouts and
intervals described
?
A
cep
ed addressed
ely ed
poorly addressed
y
ely ed
adequately addressed
y
d poorly addressed
y
d adequately addressed
y
d adequately addressed
u
y adequately n
e
Analyses
conducted in ITT populati
on?
Bias min
randomisanumber security nblinding, of attrition
yes
Randomismethod aconcealmreported
yes
Well condwith exceblinding aconcealm
yes
Study coblinded intervieweblinded.
yes Researchdata wasgroups
unclear
Non bresearcheconcealmallocation
no Control
O
nimisation? If biasbias
ation (end of social
number ), no no reporting
n rates
Non-bobserconceaddrerandoinflueeffect
sation and allocation ment not
Non influe
ducted study eption of non and allocation
ment
Non obserallocaconceaffecteffect
oordinator not but
ers were
her collecting s blinded to
blinding of ers or
ment of groups
Non influe
group had No
Overall assessment
sed, how would affect results?
R
qa
blinding of rver, allocation ealment not essed and poor omisation could nce intervention t
blinding could nce investigators ye
blinding of rvers and ation ealment could t intervention t
ye
ye
ye
blinding could nce investigators
ye
blinding could ye
KCE Report 1
Research
uestion answere
d?
Risk of
es high
es low
es low
es low
es low
es high
192S
bias
KCE Reports 19
Study
Appre
clefocuques
addre
Luciano
2011 adeqaddr
Mancuso
2011 adeqaddr
Oerlemans 2011
adeqaddr
Powell 2010
adeqaddr
92S
ropriatand
early ussed stion?
Randomisd?
essed
quately ressed
well covere
quately ressed
well covere
quately ressed
adequatelyaddressed
quately ressed
adequatelyaddressed
e Observer
blinded?
Alcon
addressed
ad
ed not
reported adad
ed not
addressed
adad
y d
not addresse
d ad
y d
adequately
addressed
adad
Internal validity
location ncealmen
t?
Patiengroup
comparae?
ddressed addresse
equately ddressed
well covered
equately ddressed
well covered
not ddressed
well covered
equately ddressed
Well covered
Chronic car
t p abl
Dropouts and
intervals described
?
A
cep
ed addressed
d adequately addressed
d adequately addressed
d well
covered
d adequately addressed
e
Analyses
conducted in ITT populati
on?
Bias min
higher pelow edublinding researche
yes
no
no
High drofollow-u
analysisdefine
intentioana
no
Patienedu
control g‘attentionis they re
aspinterven
from groue.g. ed
sheets b
O
nimisation? If biasbias
ercentage of ucation, no
of ers
influeassist
-
-
p-out rate at p, therefore
s cannot be ed as an on-to-treat alysis.
Post hbetwe
comthat, oexpe
fav
qualm
inte
nts in the ucation
group were n control’ that ceived some
pects of ntion apart up meetings ucation tip
by mail, and
Cre
inteaffe
effect
Overall assessment
sed, how would affect results?
R
qa
nce research tant
hoc comparisons een dropouts and
mpleters indicate overall, dropouts erienced a more vourable IBS-
related
lity of life, which may influence ervention effect
Control group eceived some
benefits of ervention may ect intervention t between groups
Research
uestion answere
d?
Risk of
yes low
yes low
yes low
yes low
149
bias
w
w
w
w
150
Study
Appre
clefocuques
Rice 2009‡
adeqaddr
Ringstrom 2010
adeqaddr
Rosal 2011¥
adeqaddr
Sahebalzamani 2009
adeqaddre
Sun 2010 adeqaddr
Wakabayashi 2011
adeqaddr
Watson 2009
adeqaddr
ropriatand
early ussed stion?
Randomisd?
quately ressed
adequatelyaddressed
quately ressed
adequatelyaddressed
quately ressed
adequatelyaddressed
quately essed
not reported
quately ressed
adequatelyaddressed
quately ressed
well covere
quately ressed
adequatelyaddressed
e Observer
blinded?
Alcon
y d
not reported
not
y d
not addresse
d ad
y d
not addresse
d ad
d not
addressed
ad
y d
not addresse
d
adad
ed not
addressed
wel
y d
not addresse
adad
Internal validity
location ncealmen
t?
Patiengroup
comparae?
t reported adequateaddresse
not ddressed
well covered
not ddressed
well covered
not ddressed
well covered
equately ddressed
poorlyaddresse
l covered adequateaddresse
equately ddressed
adequateaddresse
Chronic care
t p abl
Dropouts and
intervals described
?
A
cep
ely ed
adequately addressed
d adequately addressed
d adequately addressed
d not addressed
y ed
adequately addressed
ely ed
well covered
ely ed
well covered
e
Analyses
conducted in ITT populati
on?
Bias min
follow- uc
no No ment
ITT in mre
no
There wblin
participanpersonne
NR Non blind
persopart
NR No mblinding a
yes
Age of shigher th
researblinded to
no Well des
but no
yes Resea
bl
O
nimisation? If biasbias
p telephone calls.
ion of use of methods or esults
Higcould
treae
was lack of ding of
nts and study el and use of ITT
Non-perso
ITT bo
inte
ding of study onnel and icipants
Non-pe
influ
ention of and drop-outs
studypat
blindeaffe
study group han control, rchers not o intervention
No influe
signed study o blinding
No influe
rchers not inded
No influe
Overall assessment
sed, how would affect results?
R
qa
h drop out rate d have influenced tment effects in
either groups
blinding of study onnel and lack of
analysis could oth influence
ervention effect
blinding of study ersonnel could uence treatment
effect
y personnel and tients were not ed and this could ect intervention
effect
blinding could nce investigators
blinding could nce investigators
blinding could nce investigators
KCE Report 1
Research
uestion answere
d?
Risk of
yes low
yes low
yes low
yes high
yes low
yes low
yes low
192S
bias
w
w
w
h
w
w
w
KCE Reports 19
Study
Appre
clefocuques
Wearden 2010
adeqaddr
Williams 2011
wcov
Yoo 2009 adeqaddr
† Methods to Bake‡ online appendix s¥ methods of Rosa
3.5.4. Data e Reference,
country,
N of sites
Type ofchronicdisease
Baker 2011
heart fai(HF)
92S
ropriatand
early ussed stion?
Randomisd?
quately ressed
well covere
well vered
well covere
quately ressed
not reporte
r 2011 detailed in De Wsupplement to Rice 20l 2011 RCT were docu
extraction table o
f c e
Population andparticipants
ilure Total: n = 605. Intervention =27control =259
e Observer
blinded?
Alcon
d
ed not
reported wel
ed
adequately
addressed
adad
d not
reported not
Walt 2009 publication010 with additional stuumented in a p
of included RCTs
d Intervention
72 Self-manageme BEI (see contro
Internal validity
location ncealmen
t?
Patiengroup
comparae?
l covered well
covered
equately ddressed
adequateaddresse
t reported adequateaddresse
dy methods reported
Ts
Control
ent
ol)
Brief education intervention
Chronic car
t p abl
Dropouts and
intervals described
?
A
cep
d well
covered
ely ed
adequately addressed
ely ed
adequately addressed
Time of follow up and main study measure
30 to 60 days
HF knowledge and self-care behaviour:
e
Analyses
conducted in ITT populati
on?
Bias min
no Resea
bl
yes
Well desalthough t
blinrese
yes
No drando
blinding oconc
Results-self-efficacy/self-care/knowledge
Self-efficacy: TTG group :significantly greater increase in self-efficacy than thBEI group (change
O
nimisation? If biasbias
rchers not inded
No influe
signed study there was no ding of
earchers
No influe
etails on omisation, or allocation
cealment
randfavoNo
influe
Results-clinicaQoL
e
QoL improved in group compared BEI change frombaseline (6.7 vs -p<0.001)
Overall assessment
sed, how would affect results?
R
qa
blinding could nce investigators
blinding could nce investigators
Improper omisation could
our either group. blinding could nce investigators
al and Results-hecare use
TTG with -0.66,
NR
Research
uestion answere
d?
Risk of
yes low
yes low
yes high
ealth Interpretatiovalue of RCTdecision ma
Promising refor improvingpatient’s self-efficacy, and
151
bias
w
w
h
on of T for
aking
sults g -self-
152
Reference,
country,
N of sites
Type ofchronicdisease
USA
4 sites
Barlow et al 2009 UK 1 site
Multiple sclerosis(MS)
f c e
Population andparticipants
Setting: 4 univehospitals
Current use of ldiuretics
Class II-IV symptoms in thepast 6 months
Age: mean 61 years
52% male
37% low literacy
31% serious HF
s Total n=216
Intervention=78waiting list group=64, comparison group=74
subjects with Mmainly identifiedthrough MS Socdatabases, to oChronic DiseaseSelf-ManagemeCourse (CDSMCintervention gro
Some patients
d Intervention
ersity
oop
e
y
F
followed by GroTeach to Goal (TTG) educatiospecific instructon daily weight monitoring and recording, diureself-adjustment5 to 8 Follow upphone calls in nmonth to reinfoeducation and guide patient toward better semanagement sk(based on sociacognitive theory
8,
S, d ciety r a e
ent C;
oup).
The CDSMC consisted of sixweekly 2-hour group sessionsdelivered by paof trained lay tutors. The couis largely interactive, encouraging participants to apply new skills
Control
oup-
n: tion
etic t. p next rce
elf-kills. al y)
(BEI): 40 minutes long review : daily self-assessment and action planning in 4 specific domains + educational manual + new digital scale
x
, airs
rse
s.
no intervention (waiting list; control group)
Chronic care
Time of follow up and main study measure
adapted ImprovingChronic Illness Care Evaluation (ICICE) telephone survey
QOL: Heart Failure (HFSS)
Data (questionnaires) were collected at baseline, 4 months and 12 months. The primary outcomes were self-efficacy and depression; secondary outcomes were health status and self-management behaviours. Self-efficacy was assessed both
e
Results-self-efficacy/self-care/knowledge
from baseline of 1.0vs 0.4, p=0.006), on10 items scale Self care: both groups improved - greater improvemenin the TTG group (1vs 3.2, p<0.001) on10 items scale .
Intervention improveself-management self- efficacy (effectsize (ES) 0.30, p=0.009) and physical status (ES 0.12, p=0.005). Thewere no other statistically significachanges. However,trends towards improvement on depression (ES 0.2p=0.05) and MS selefficacy (ES 0.16, p=0.04) were noted
Results-clinicaQoL
0 n a
nt .8 a
ed
t
ere
ant
1, lf-
d.
NR
al and Results-hecare use
NR
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
care but the slength of follo(1 month) madifficult to evathe lasting vathis intervent
Generalisableany hospital setting?
Well to most patients (37%literacy )
Some improvein self-efficacymaintained at month follow uoverall effect swere small anoutcomes reastatistical significance. Tresults from thtrial give no indication to recommend thCDSMC for Mpatients. Largtrials are warr
192S
on of T for
aking
short ow up ake it aluate alue of tion.
e to
: low
ement y was 12-
up but sizes
nd few ched
The his
he MS
er anted.
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
Berman et al 2009
USA
Single site
Chronic pain
92S
f c e
Population andparticipants
chose not to attthe CDSMC so formed a (comparison grothese patients won average oldehad suffered froMS longer and were less anxiothan patients whchose to attend
Total: n=78
intervention = 4waiting list =37
Setting: commu
Aged ≥55 yearswith ≥1 day in thprevious 30 daywhen pain madedifficult to do usactivities and/orleast moderate levels of pain onaverage, had ba
familiarity with computers, andcould read and
d Intervention
end
oup; were er, om
ous ho .
1
unity
s, he ys e it
sual r at
n asic
The interventionwebsite comprisan introductory module describa problem-solviapproach to planning for change, based the 6-stage modoutlined by Prochaska et a(reference 49 inBerman). Participants weasked to try eacmodule at leastonce and to usethe website at leonce a week foweeks.
Control
n sed
bing ng
on del
l n
ere ch t e east r 6
Waiting list
Chronic car
Time of follow up and main study measure
specifically for MS (MS self-efficacy; reference 27 in Barlow) and by a generic measure (self-management self-efficacy; reference 26 in Barlow). Physical and psychological status was measured using the Multiple Sclerosis Impact Scale (reference 28 in Barlow).
6 weeks
Self-efficacy ,
pain intensity,
depression,
anxiety,
awareness of responses to pain, self-care and satisfaction with and use of the intervention
e
Results-self-efficacy/self-care/knowledge
(i) Pain intensity decreased by -0.64 ±1.48 (p=0.01) in thintervention vs -0.7±1.82 (p=0.05) in thecomparison group (ii) (i) Pain interfe-rence decreased by1.21±2.44 in inter-vention (p=0.01) vs 0.88±2.08 (p=0.01) comparison group (iii) Self-efficacy (PSEQ) increased b1.83±8.72 (p>0.05) intervention vs 0.5612.4 (p>0.05) in
Results-clinicaQoL
he ±
e
y -
-in
by in
6±
(i) depressive scodecreased by -1.5.82 (p>0.05) in intervention vs 0.±5.14 (p>0.05) incomparison grou (ii) anxiety scoresdecreased by -0.4.74 (p>0.05) vs 0.91±3.28 (p>0.0comparison grou
al and Results-hecare use
ores 5±
.37 n p
s 64±
05) in p
ealth Interpretatiovalue of RCTdecision ma
Findings confithe feasibility
6-week interneself-care educprogramme inadults with chpain but no strevidence to recommend thintervention.
However it is difficult to generalise theresults given tparticipants wcomputer liter
153
on of T for
aking
irm of a
et cation n older ronic rong
his
e that
were ate
154
Reference,
country,
N of sites
Type ofchronicdisease
Bosworth et al 2009a
(Am Heart J)
USA
1 site
Hyperteon
f c e
Population andparticipants
understand
English. Patients with chronic pain duearthritis, spinal problems, previinjuries or surgeand sciatica
nsi 2 level (primary care provider anpatient) cluster randomised triaincluding 588 patients with hypertension- hfilled a prescriptfor hypertensivemedication in thpast year: 4 groups.
group 1:
combined providdecision supporplus patient behavioural intervention, n=
group 2: providedecision supporpatients usual cn=151.
d Intervention
e to
ous ery
nd
al,
ad tion e he
der rt
150
er rt , care,
2 Interventions;patient and provider 1.Patient: bimonthly tailornurse-deliveredbehavioural telephone intervention (delivering scripinformation drawfrom 9 educatioand behaviouramodules) to improve hypertension treatment. 2. provider decisupport, primarcare providers received, at eacvisit, either computer-generated decissupport (design
Control
;
red d
pted wn
onal al
ision ry
ch
sion ned
Patients: Usual care Providers: Hypertension reminder
Chronic care
Time of follow up and main study measure
Follow up at 6 and 24 months.
The primary outcome was proportion of patients who achieved a BP <140/90 mm Hg (<130/85 for diabetic patients) over the 24-month follow up.
e
Results-self-efficacy/self-care/knowledge
comparison group. (iv) Increase in confidence in abilityto use self-care techniques to manage pain by 0.81±1.27 (p=0.01) intervention vs -0.16±1.8 (p>0.05) incomparison group NR
Results-clinicaQoL
y
in
n
no significant differences in amof change in bloopressure control three interventiongroups comparedthe hypertension reminder control In secondary anarates of blood precontrol for all patreceiving the behavioural intervimproved more thpatients in the nobehavioural intervgroup, but there wbetween-group difference at the the study. There was 14.4%improvement in b(p=0.03) in the pabehaviour intervebut no between-gdifferences at theof the study.
al and Results-hecare use
mount od in the n d with
group. alyses, essure ients
vention han for on-vention was no
end of
% bp atient ention group e end
The number primary healthcare vover the 24 months was similar betwethe 4 groups
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
and could reaunderstand
English
of
visits
een s.
Limited evideto recommencomputer-badecision supmanagementsystem for prcare providerthe nurse leatelephone intervention. population wretired veteraand predominmale so maybe generalisato general population.
192S
on of T for
aking
d and
ence nd sed port t rimary rs or
ad
Study as
ans nantly
y not able
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
Bosworth et al 2009b
(Ann Intern Med)
USA
2 sites
hypertenn
92S
f c e
Population andparticipants
group 3: patientbehavioural intervention, provider no hypertension reminder, n=144
group 4: providehypertension reminder, patienusual care, n=1
mean age= 63 years
98% male
25% smokers
37% diabetes
nsio hypertension diagnosed for aleast 12 monthshypertensive medication use.
n=636
behavioural intervention, n=160, usual can=159, home Bmonitoring, n=1combined homemonitoring and behavioural
d Intervention
t
4.
er
nt 43
to improve guideline concordant medtherapy) The acintervention for primary care providers supplpatient-specific recommendatioabout hypertensdecision suppodelivered at thepoint of care dueach patient vis
at s,
.
are, P 58,
e
Tailored behavioural selmanagement intervention (covered percerisk for hypertension, memory, literacsocial support, relationship withhealth care providers, side effects of hypertensives, weight loss, reduced sodiumintake, exercisesmoking cessat
Control
dical ctive
ied
ons sion rt
e uring sit.
f-
ived
cy,
h
m e, tion,
usual care or home BP monitoring (measure BP 3 times a week)
Chronic car
Time of follow up and main study measure
Primary outcome was proportion of patients with adequate BP control at 6, 12, 18 and 24 months. BPcontrol was defined as systolic < mm140Hg and diastolic < 90 mmHg. Secondary outcomes were systolic and diastolic BP at each study time
e
Results-self-efficacy/self-care/knowledge
NR
Results-clinicaQoL
The combined intervention had tgreatest increaseproportion of patiwith BP control (1p=0.012), behavigroup (4.3%, p=0home monitoring(7.6%, p=0.096) compared with uscare.
al and Results-hecare use
the e in ents 11%, oural
0.34), group all sual
The number outpatient viswere similar the 4 groups
ealth Interpretatiovalue of RCTdecision ma
of sits for
s
The combinaof behaviouraintervention btelephone anhome BP monitoring wsuccessful indecreasing Bover 24 montThe behaviouintervention wonly successwhen combinwith BP hommonitoring.
155
on of T for
aking
ation al by nd
was n BP ths. ural was sful ned e
156
Reference,
country,
N of sites
Type ofchronicdisease
Bucknall et al 2012
UK
6 sites- hospital
COPD
Cadilhac
et al 2011
Australia
stroke
f c e
Population andparticipants
intervention, n=
49% African America, 66% female. Mean a61 years
Total = 464
Intervention=23control=232
Patients with COPD admittedhospital with anacute exacerbaof COPD.
FEV1 <70%.
Excluded patienwith asthma or lventricular failurmalignant diseaor poor memory
mean age 69 ye
male 37%
current smoker 39%
Stroke patients;
mean age
69 years;
78% had strokelast 12 months, female 59%
d Intervention
159
age
reduce alcohol intake).
32,
d to tion
nts left re,
ase y.
ears
Self-support management programme delivered by tranurses in four fortnightly homevisits, each lastabout 40 minuteAll patients received a diarycard.
;
e in
Stroke self-management programme (SSMP)- 8 weeThe generic programme wasStanford chronicondition self-
Control
ained
e ting es.
y
Control group – managed by their GP or hospital based specialists.
eks
s a c
generic intervention (range of topics – appropriate use of medicines, communicatio
Chronic care
Time of follow up and main study measure
point.
Primary end point – time to first acute hospital admission with COPD exacerbation or death due to COPD within 12 months.
Secondary endpoints: change in baseline in St George’s respiratory questionnaire and EuroQol 5D.
Primary outcomes were recruitment, participation, and participant safety. Secondary outcomes were positive and active
e
Results-self-efficacy/self-care/knowledge
No significant differences in COPDself-efficacy scales
Overall, 52% completed the SSMand 38% completedthe generic intervention (p=0.18There were no adverse events attributable to eithe
Results-clinicaQoL
D No significant difference in risk hospital admissiodeath due to COP
MP d
8).
r
NR
al and Results-hecare use
of on or PD
No significandifference
NR
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
nt This interventishould not be implemented iCOPD patientas no effects ooutcomes werfound. Also it appears difficuencourage COpatients to participate.
No evidence recommend tSSMP as thewas no impaself-managemoutcomes compared wi
192S
on of T for
aking
ion
into t care on re
ult to OPD
to the ere ct on ment
th
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
7 sites (hospital)
Chan et al 2009
China
1 site
Schizopnia
92S
f c e
Population andparticipants
hre schizophrenic patients, recruitfrom the psychiaout-patient department of ahospital, and thecaregivers. Participants werrandomised to intervention, n=or usual care n=
patients:
male 66%
d Intervention
management programme. ThSSMP differed the generic programme by includes stroke survivors, havingreater contact time, only beingdelivered by professions skilin stroke and trained by the National StrokeFoundation, providing targetstroke-specific information eacweek and revisinformation
ed atric
a eir
re
36 =37
Psychoeducatiopsychoeducatioprogramme (reference 18 inChan), which wbased on the framework advocated by thPsychoeducatioWorking Party othe EPPIC. 10 sessions conducted weefor 3 months, conducted by amental health nurse
Control
he from
only
ng
g
lled
e
ted
ch iting
n, nutrition) Usual care
on onal
n was
he onal of
kly
a
Usual care
Chronic car
Time of follow up and main study measure
engagement in life using the Health Education Impact Questionnaire (ref 15 in Cadilhac), and characteristics of QoL (ref 16 in Cadilhac) and mood (ref 17 in Cadilhac) at 6 months from programme completion
Patient assessments: Rating of Medication Influences (ROMI), ( 19-item questionnaire for patient’s subjective view of the reasons for taking antipsychotic medication);
Brief Psychiatric Rating Scale (BPRS),(18-item
e
Results-self-efficacy/self-care/knowledge
intervention.
For caregivers, significant group differences were detected by the U-test for the SES scoat the post-1 (p=0.007) and post-(p<0.001) time pointhe level of satisfaction at the post-1 (p=0.033) anpost-2 (p<0.021) timpoints, and the FIBSscore at the post-2 time point (p=0.043 For patients,
Results-clinicaQoL
ore
-2 nts,
nd me S
).
NR
al and Results-hecare use
NR
ealth Interpretatiovalue of RCTdecision ma
usual care.
The PEP intervention improved patieadherence to medication, brpsychiatric ratand treatmentattitudes. Careshowed a significant improvement self-efficacy rabut this effect declined after intervention tomatch the congroup at 12 months. The
157
on of T for
aking
ent’s
rief ting t ers
in the ating
the o ntrol
158
Reference,
country,
N of sites
Type ofchronicdisease
f c e
Population andparticipants
mean age 35.3 years
Chinese
Caregivers:
Female 89%
Family member97%
d Intervention
r
Control
Chronic care
Time of follow up and main study measure
questionnaire - patient’s mental condition)
Insight and Treatment Attitudes Questionnaire (ITAQ),( 11 items to assess a patient's insight into his or her illness)
Caregivers, assessments: Family Burden Interview Schedule (FBIS), a 24-item scale on the burden of care); General Perceived Self-efficacy Scale (SES) is a 10-item scale, a measure for a person’s competence in dealing with challenging and stressful life situations;
6 item Social Support Questionnaire
e
Results-self-efficacy/self-care/knowledge
significant group differences were detected by the U-test for the ROMI score at the post-1 (p=0.003) and post-(p=0.012) time poin the BPRS score at the post-2 (p=0.017time point, the ITAQ score at thpost-1, post-2, and post-3 time points (ap<0.01).
Results-clinicaQoL
-2 nts,
7)
he
all
al and Results-hecare use
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
generalisabilitthis study is limas it is set in aChina, the patwere predomimale and the caregivers predominantlymothers.
192S
on of T for
aking
ty of mited a tients nantly
y
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
Chen et al 2011 Taiwan 1 site
Chronic kidney disease
92S
f c e
Population andparticipants
54 incidental predialysis chrokidney disease patients (CKD, stages III to V), recruited from aoutpatient clinicTaiwan. Patientwere randomiseto either an SMSn=27 programmor not n=27
d Intervention
onic
an c in ts ed S
me
The SMS programme included the provision of information, reinforced learnincentives and encouraging secare and maintenance oftherapy, implemented bymultidisciplinaryteam of nurses,dieticians and volunteers. Thewere monthly fato-face meetingweekly telephonsupport and a support group ta month. In
Control
ning
elf-
f the
y a y ,
ere ace-gs, ne
wice
control
Chronic car
Time of follow up and main study measure
(SSQ-6), to assess the number of persons available as support providers and the level of satisfaction with available support.
Follow-up: immediately after the intervention (post-1), 6 months (post-2) and 12 months (post-3)
The primary endpoints were absolute eGFR change and number of hospitalisations. Secondary endpoints included eGFR decrease of up to 50% and all-cause mortality. Duration of follow-up was 12 months.
e
Results-self-efficacy/self-care/knowledge
CKD knowledge improved significancompared with non-SMS patients after months(10.13 vs 5.5points, p<0.001)
Results-clinicaQoL
tly -12 51
At the end of the the absolute eGFsignificantly highethe SMS group ththe control group(29.11+/-20.61 vs15.72+/-10.67 mlp<0.05). There walso fewer hospitalisations inSMS group (18.544.47%, p<0.05)EGFR reduction was seen in 3.7%intervention grou33.3% in the congroup (p<0.05). Nother significant differences were
al and Results-hecare use
study, FR was er in han in
p s l/min,
were
n the 50% vs . <50%
% in the p vs trol
No
found.
NR
ealth Interpretatiovalue of RCTdecision ma
SMS improvedpatients knowof their diseasimproved eGFand patients hfewer hospitalisationevents compawith the controgroup, howevetheses resultsbe viewed withcaution as thesample size mthe study waspowered sufficto detect betwgroup differen
159
on of T for
aking
d wledge se, FR had
n ared ol er
s must h
e small meant not ciently
ween nces.
160
Reference,
country,
N of sites
Type ofchronicdisease
Chow et al 2010
Hong Kong
multicentre
peritonedialysis patients
f c e
Population andparticipants
eal Total: n=85
Intervention =43
Control =42
Setting: hospita
d Intervention
addition, specifmeasures wereimplemented fopatients by disestage, includinglectures or discussions.
3
al
The interventionconsisted of a comprehensivedischarge plannprotocol (involvfamily membersand a standard6-week nurse-initiated telephofollow-up regim(Brooten & Youngblut 2006Chow), with theaim of achievingshared objectivand reinforcing health-related behaviours.
Control
ic e or ease g
n
e ning ing s) ised
one en
6 in e g of es of
Patients in the control group received routine hospital discharge services
Chronic care
Time of follow up and main study measure
Kidney disease quality of life was measured for each patient at
three time intervals: before the intervention, at completion of the 6-week intervention
and 6 weeks after completion of the programme
e
Results-self-efficacy/self-care/knowledge
NR
Results-clinicaQoL
The results of theoutcome measurquality of life wermixed. A non-statistically signifmain effect for intervention (between-groupsobserved in all ofparameters. However, statisticsignificant within-(time) and interaction efwere observed invariables acrosstime, including Symptoms, EffecKidney Disease, Role-physical, PaEmotional Well-band Social Funct(Table 3). To detethe attribution of effects The variathat demonstrateinteraction effects(P < 0Æ05) wereQuality of Sleep,
al and Results-hecare use
e res of re
ficant
s) was f the
cally -group
ffects n some
cts of Sleep,
ain, being ion ermine time bles
ed s
e Staff
NR
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
No between gdifferences imthat standard is not significaworse – regarHRQoL – thannurse-led casemanagement patient group.Patients in thisstudy were recruited fromhospitals with specialized recare facilities staff. Hence recannot be generalized foother patients non-specializeclinical setting
192S
on of T for
aking
group mply
care antly rding n e in this s
m
nal and esults
or in
ed gs
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
Ghahari et al 2010
Australia
extremefatigue (FatigueSeverityScale scof 4) andneurologl diagno(multiplesclerosispost-polParkinso
92S
f c e
Population andparticipants
e
e y core d gicasis
e s, io, on)
Total: n=95
fatigue self-mangement group (S=34
Self-managemeinformation only(IO) =28
Control =33
Aged ≥20 yearshad self-reporteaccess to the Internet three timper week for at
d Intervention
na-SM)
ent y
s, ed
mes
Seven-week onprogramme usideconstruction-reconstruction process. Conteincluded impor-tance of rest, communicationbody mechanicrearranging actstations, settingpriorities and standards and balancing a schedule) Information-onlygroup: weekly information via Internet. Conten
Control
nline ng a -
nt -
, s, ivity
g
y
the nt
Participants continued to receive routine care ranging from nothing to specialist care and/or community care
Chronic car
Time of follow up and main study measure
Outcomes were pre/post-test QoL (Personal Well being Index), activity participa-tion (activity card), impact of fatigue, depression (depression anxiety and stress scale) , social support, self-efficacy (Generalised self-efficacy scale) and essential computer skills
e
Results-self-efficacy/self-care/knowledge
(i) The three groupswere significantly different (F(2,86) = 3.797, p< 0.05) in their level of self-efficacy. (ii) Both SM and IO groups had higher levels of self-efficacthan the control groat post- test althougafter using Bonferrofor correction of multiple comparisonit showed the resultto be marginal (p=0.057 for the SM
Results-clinicaQoL
Encouragement,Patient SatisfactiSocial Functionininteraction effect for PhysicaFunctioning showtrend towards statistically signif(P = 0Æ06). The results confirthat the quality ofthe intervention group patients wahigher than that ocontrol group in about 50% of thedimensions in KD
s
cy oup gh oni
ns ts
M
Post-hoc testing showed the differin well-being to bbetween the information-only acontrol groups wiinformation-only ghaving significantbetter outcomes 0.036)
al and Results-hecare use
on and ng. The
al wed a
ficance
rmed f life of
as of the
e DQOL.
rence be
and ith the group tly (p=
NR
ealth Interpretatiovalue of RCTdecision ma
No evidence recommend tintervention dvery few significant improvementcompared wicontrol groupThere was improvementthe ‘informationly’ group. Lof group differences mbe due the stbeing under-
161
on of T for
aking
to this due to
ts th the
p.
t in ion Lack
may tudy
162
Reference,
country,
N of sites
Type ofchronicdisease
Hochhalter et al 2010
USA
Single site
Multiple chronic illnesses(MCI)
f c e
Population andparticipants
least 1 hour andminimum
s
Total: n=79
Intervention gro=26
Safety group =2
Usual care =26
Setting: hospita
Aged ≥65 yearsand pre- treated≥2 of seven qualifying chronillnesses; (1) arthritis, (2) lungdisease, (3) headisease, (4)
diabetes, (5) hypertension, (6
d Intervention
d a identical to the written materialused in the fatigself-managemeprogramme
oup
27
al
s d for
nic
g art
6)
Intervention andsafety groups attended a 2-howorkshop and participated in medical encounphone calls. ThIntervention Grodiscussed patieengagement concepts from publicly distribucontent. The SaGroup discussegeneral safety (e.g., fire safetyidentity theft)
Control
gue ent
d
our
nter e oup ent
uted afety ed
y,
Usual care as directed by physician or family doctor
Chronic care
Time of follow up and main study measure
6 months
Health-related quality of life, Self-Efficacy for Managing Chronic Disease, Communication with physicians scale, Patient Activation Measure, Self-reported health care utilization
e
Results-self-efficacy/self-care/knowledge
and p=0.058 for theIO group)
(i) Patient ActivationMeasure scores: Significant increasestandardized mean Patient Activation Measure score fromBaseline to Follow-Uin all 3 groups (p < 0.0001). No difference between groups (ii) No significant effects or interactionof Group or Time foUnhealthy Days afteaccounting for the significant effects ofSelf-Efficacy (p < 0.001) and Low SelRated Health (p = 0.018). A post-hoc analysis
Results-clinicaQoL
e
n
e in
m Up
ns or er
f
f-
s
NR
al and Results-hecare use
NR
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
powered. Additionally, control groupshowed somimprovementperhaps this was motivateseek additionhelp as participants wnot blinded togroups.
There was improvement self-efficacy inintervention grbut overall no conclusive findto recommendintervention.
192S
on of T for
aking
the p e t group
ed to nal
were o their
in n the roup
dings d this
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
Jarrett et al 2009
USA
single site
Irritable bowel syndrom(IBS)
92S
f c e
Population andparticipants
depression, andosteoporosis
me
Total n=188
CSM-IP =58
CSM-T/IP =58
UC =60
Setting: universbased gastro-enterology prac
>18 years of agcurrent IBS symptoms (Romcriteria), patientwith co-morbiditexcluded.
d Intervention
d (7)
sity-
ctice
ge,
me-II ts ties
self-managemeby:
1. sessions delivered in-per(CSM-IP)
2.sessions delivered by telephone (CSMT/IP) apart from2nd and last session.
The interventionwas delivered inone hour sessioby psychiatric nurse practitionIt covered 4 themes –
Control
ent
rson
M-m 1st,
n n 9 ons
ners.
usual care (UC) (continuation of treatment recommended by their health-care provider)
Chronic car
Time of follow up and main study measure
12-months
Gastrointestinal symptom score and QOL, cognitive beliefs, IBS symptom score, psychological distress
e
Results-self-efficacy/self-care/knowledge
showed a statisticalsignificant improvement in selfefficacy for self-management in theintervention group (p=0.042). (iii) Only the Safety Group showed a significant change from Baseline to Follow-Up in the percent of group members reporting High Self-Rated Health (p = 0.013)At 12 months, therewas Significant improvements in cognitive beliefs in CSM-IP vs UC (-1.1vs -0.46, p<0.001) and CSM-T/IP vs U(-1.01 vs -0.46, p<0.001), but no difference between CSM-IP vs CSM-T/
Results-clinicaQoL
lly
f-
e
11
C
IP
At 12 months thewere significant improvements in;(i) IBS symptom sin both CSM-IP (-p<0.001) and CS(-28.4, p=0.006) v(-9.5), but no diffein CSM-IP vs CS (ii) IBS QoL in CS(12.2, p=0.010) aCSM-T/IP (11.90p=0.029) vs UC (but no differenceCSM-IP vs CSM- (iii) in psychologicdistress in CSM-I(0.05, p=0.009) bCSM-T/IP (-0.08,
al and Results-hecare use
ere
; score -25.6,
SM-T/IP vs UC erence
SM-T/IP
SM-IP and 0, (7.4) in -T/IP
cal IP but not ,
NR
ealth Interpretatiovalue of RCTdecision ma
Self-manageprogramme delivered by telephone or totally in-perseffective in improving IBSsymptoms anQol, howeverstudy populanot represenof the generapopulation assubjects weremainly femalwhite and relatively weleducated.
163
on of T for
aking
ment
son is
S nd r this tion is tative
al s the e e,
ll
164
Reference,
country,
N of sites
Type ofchronicdisease
Jerant et al 2009
USA
12 sites
Chronic illness
f c e
Population andparticipants
Total n=415
HIOH via home visits n=138, HIvia phone calls n=139, usual can=138
Setting: universaffi liated primarcare network.
Aged 40 years aolder and
who had 1 or mof 6 common chronic illnesse(arthritis, asthmchronic obstruct
pulmonary disea
d Intervention
education, diet (identify problemin their diet), relaxation (abdominal breathing, musirelaxation)and cognitive behavioural (baon individual assessment) strategies.
OH
are
sity-ry
and
ore
s a, tive
ase,
Homing in on Health (HIOH) delivered in (I homes or (ii) by telephone HIOH is similar content to ChroDisease self management program (CDSM 6 weekly sessiothat aim to masself-managemetasks such as exercising safecoping with diffiemotions and ucognitive symptmanagement
Control
ms
ic
ased
e
in onic
MP).
ons ster ent
ly, icult
using tom
Usual-Care group were initially visited in their home by the study nurse, and completed the follow-up telephone questionnaires. They otherwise received care from their usual clinician
Chronic care
Time of follow up and main study measure
6 weeks, 6 months and 1 year
illness management self-efficacy, Health status, Medical Outcomes Study 5-item general health,EuroQol
e
Results-self-efficacy/self-care/knowledge
Compared with usucare, HIOH deliverein the home led to significantly higher illness managemenself-efficacy at 6 weeks (effect size =0.27; 95% CI, 0.10-0.43) and at 6 mont(0.17; 95% CI, 0.010.33), but not at 1 year
Results-clinicaQoL
p=0.457) vs UC (
al ed
t
= -ths -
(i) In-home HIOHno significant effeHealth survey‘s physical compon(PCS-36) or mencomponent (MCSsummary scores,
(ii) For EQ-VAhome group scorwere higher thancontrol group at 6weeks (0.41; 95%0.15-0.67; p = 0 .6 months (0.31; 9CI, 0.05-0.57; p =and 1 year (0.40;CI, 0.14-0.66; p =and higher than itelephone group year (0.30; 95% C0.03-0.56; p = .03
al and Results-hecare use
(0.13).
H had ects on
ent ntal S-36) ,
AS, res in the 6 % CI, .002); 95% = .02), ; 95% = .003), n the at 1 CI, 3)
NR
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
This peer-ledchronic illnesself-managemprogramme l
Only one significant efon only one secondary measure (Euhealth statusmeasure)at 1months. Therno evidence recommend tintervention.
192S
on of T for
aking
d ss ment ed to
ffect
uroQol s 12 re is to this
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
Luciano et al 2011
Spain
3 sites
Fibromya
Mancus Asthma
92S
f c e
Population andparticipants
congestive hearfailure, depress
and/or diabetesmellitus) plus functional impairment.
yalgi Total: n=216
Intervention =10
Usual care = 10
Setting: GPs
Aged 18 - 75 ye
contactable by telephone, and met the diagnoscriteria of FM established by tACR.
Total: n=296
d Intervention
rt ion,
s
techniques.
08
08
ears,
who stic
the
psychoeducativprogram, nine 2hour sessions (sessions of education and 4sessions of autogenic relaxation). Education sesscontained information abosymptoms, comorbid medicconditions, causof the illness, psychosocial factors on pain treatments. Autogenic relaxation sessions, pain relief, stress reduction.
Intervention wa
Control
ve 2 (5
4
sions
out
cal ses
and
usual care from their GP (pharmacologic and is adjusted to the symptomatic profile of the patient)
as Three
Chronic car
Time of follow up and main study measure
2 months
functional status (FIA), The State Trait Anxiety Inventory, The Marlowe-Crowne Social Desirability Scale
Asthma quality of
e
Results-self-efficacy/self-care/knowledge
Compared with the control group, the intervention group reported (i) better functionalstatus (FIQ) than thcontrol group (p=0.001) (ii) less physical impairment (p=0.00 (iii) less days not feeling well (p=0.00 (iv) less pain (p=0.001) (v) less general fatigue (p=0.005) (vi) less morning fatigue (p=0.001) (vii) less stiffness ( 0.007) NR
Results-clinicaQoL
e
01)
01)
p=
Compared with thcontrol group, theintervention groureported (i) less anxiety (p=0.001) (ii) less depressio(p=0.001)
For controls, the
al and Results-hecare use
he e p
on
NR
During the fi
ealth Interpretatiovalue of RCTdecision ma
Specific improvementsthe short termmonths) in thispsycho-educaintervention : physical functdays feeling wpain, general fatigue, mornifatigue, stiffneanxiety, and depression. However, thesresults were reported at theof the intervenno longer termevidence avaiA placebo effe(group dynamcannot be exc
rst 8 A self-
165
on of T for
aking
s in m (2
s ational
ion, well,
ng ess,
se
e end ntion: m lable.
ect mics) cluded
166
Reference,
country,
N of sites
Type ofchronicdisease
o et al 2011
USA
2 sites
Oerlemans et al 2011
Netherlands
Multi-sites
irritable bowel syndrom(IBS)
f c e
Population andparticipants
Intervention =14
Control=148
Setting: emergedepartment (ED1 university hospital, and 1 church hospital.
Known diagnosasthma, and ca
to the emergencdepartment (EDbecause of respiratory symptoms.
Age: ≥18 years.
me
Total =76
Intervention =38
Control =38
Setting: GP surgeries
Suffering from Iaccording to theInternational Classification of
d Intervention
48
ency D) of
.
is of me
ce D)
.
based on socialearning theoryimplemented through the precede-proceemodel of healthbehaviour. At enrolment, intervention patients were ga workbook containing 20 chapters addressing asthknowledge andself-efficacy, thecontacted weekby telephone.
8
BS e
f
Standard care pcognitive-behavioural therapy (CBT). Intervention groreceived situatiofeedback focuson IBS complaicatastrophizingthoughts, dysfunctional cognitions, andavoidance behaviorr, and w
Control
l
ed h
iven
hma
en kly
brochures from the American Lung Association, providing information about basic asthma pathophysio-logy, triggers, and use of peak flow-meters, followed by telephone follow-ups
plus
oup onal ed nts,
was
standard care only (details not reported)
Chronic care
Time of follow up and main study measure
life questionnaire (AQLQ)at 8 weeks and then at 1 year.
Repeated asthma ED visits at 4, 12 and 16 weeks.
4 weeks and at 3 months
dysfunctional complaint-related cognitions and
behaviours
e
Results-self-efficacy/self-care/knowledge
Between-group comparison at 4 weeks confirmed ththere was more improvement in catastrophizing thoughts (χ2= 9.33,p<0.01, df=1). This improvement in the intervention group persisted at 3-montfollow-up (χ2=7.06, p<0.01, df=1).
Results-clinicaQoL
change in AQLQ was 1.95 95% CIto 2.16; p<0.001)For interventionpatients the chanAQLQ scores wa(95% CI:1.64 to 2p<0.001), and thedifference betweegroups was 0.11 CI –0.17 to 0.40; p=0.43)
at
h
(i) At 4 weeks thewas more overallimprovement in tintervention grou4.08, p<0.05, df=At long-term, no significant differebetween group ewere found on IBquality of life. (ii) There was significantly moreimprovement in t
al and Results-hecare use
scores I: 1.74 ).
nge in as 1.83 2.03; e en (95%
weeks, 33 patients hadleast 1 asthmED visit, withdifference between gro(13% contro11% intervenpatients), anpatients werehospitalizedfor asthma (controls, 4 intervention patients).
ere l QoL he p (χ2=
=1).
ences ffects
BS
e pain he
NR
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
at ma h no
oups ls, ntion
nd 14 e
10
managementeducation programme delivered in tED and reinfoby telephonenot provide abenefit on paquality of life repeated ED
A standard cplus CB is efficacious foimproving IBSrelated compand cognitionthe short-termThe study inconly subgrouIBS, e.g. diaror constipatioprone IBS, he
192S
on of T for
aking
t
the orced
e did any atients’
and visits.
are
or S-
plaints ns in m. cluded
ups of rrhoea on-ence
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
Powell et al 2010
USA
single site
Heart failure (H
Rice et Chronic
92S
f c e
Population andparticipants
Primary
Care (ICPC) or Rome III criteria≥3 months
Age: 18-65 year
HF) Total =902
Intervention =45
Control =451
Setting: hospita
HF with reducedpreserved systofunction, and receiving some
form of active hfailure treatmen
including diuretifor the previousmonths.
Age: 63.6 years
Gender: 47% women
c Total: n=761
d Intervention
a for
rs
mainly based ocognitive–behaviour thera
51
al
d or olic
eart nt,
ics, s 3
s;
Self-managemegroup:
18 contacts andHF educationalsheets during thcourse of 1 yeaaddition to tip sheets in groupand were taughself-managemeskills to implemthe advice.
disease
Control
n
apy
ent
d 18 tip
he ar in
ps ht ent
ment
Education group:
18 contacts and 18 HF educational tip sheets during the course of 1 year in addition to tip sheets in the mail and telephone calls to check comprehension.
usual care
Chronic car
Time of follow up and main study measure
2 - 3 years
Death or heart failure hospitalization during a median
of 2.56 years of follow-up.
12 months
e
Results-self-efficacy/self-care/knowledge
Self-efficacy scoresimproved by 0.2 points in both group(p=.008 for time effect).
NR
Results-clinicaQoL
intervention than control group at 4follow-up (χ2=5.4p<.05, df=1). No significant lonterm between-groeffects were foun
s
ps
(i) Major depresssymptoms decreato 90 (20%) in themanagement group and 99 (22the education gro(p =0.008 for timeeffect) (ii) Restricting soto ≤2400 mg/d occurred in 126 (patients in the semanagement gro81 (18%) in the education group (p=0.01)
There were 48 de
al and Results-hecare use
in 4-week 44,
ng-oup nd
sive ased e self-
2%) in oup e
dium
(28%) elf-oup and
(i) No benefiself-managecompared with educatio(Wilcoxon p=0.46) in teof death or hfailure hospitalizatio
eaths (i) After 1 ye
ealth Interpretatiovalue of RCTdecision ma
the results mnot be generalizable
t of ement
on
erms heart
on
The addition
of self-managementcounselling toeducational intervention dnot reduce deor heart failurhospitalizatio
in patients wimild to modecompared to enhanced educational intervention aBoth groups experienced decrease of approx. 20% depressive symptoms anboth groups improved selefficacy score
ar, A relatively sim
167
on of T for
aking
may
e.
t o
did eath re
on
ith erate
alone.
a
in
nd
f es.
mple
168
Reference,
country,
N of sites
Type ofchronicdisease
al 2009
USA
5 sites
obstructpulmonadisease (COPD)
Ringstrom et al 2010
Sweden
Irritable bowel syndrom(IBS)
f c e
Population andparticipants
tive ary
Intervention =37
Control =371
Setting: VeteranAffairs medical centers.
Confirmed COPat high risk for hospitalization apredicted by ≥1 the following
during the previyear: hospital admission or EDvisit for COPD,
chronic home oxygen use, or course of systemcorticosteroids f
COPD
me
Total: n=143
Group educatio=72
Guidebook =71
d Intervention
72
ns
PD
as of
ous
D
a mic for
management patients attende
a single 1- to 1 education sessincluding gener
information aboCOPD, direct observation of inhaler techniqusmoking cessatcounselling, encouragementregular exercisean action plan amonthly follow ucalls.
n
The IBS schoolwas designed othe basis of theself-efficacy
theory, and the general theory o
Control
ed
ion ral
out
ues, tion
t of e, and up
patients received a one-page hand-out containing
a summary of the principles of COPD care and the telephone number for
the 24-hour VA nursing helpline
on e
of
The IBS guidebook cover the areas such as pathophysiology, GI
Chronic care
Time of follow up and main study measure
COPD-related hospitalizations and ED visits, respiratory medication use, mortality, and change in Saint
George’s Respiratory Questionnaire
3 months, and 6 months
IBS symptom severity, gastrointestinal-
e
Results-self-efficacy/self-care/knowledge
Significantly improvment in knowledge and the satisfactionwith that knowledgein IBS group vs guidebook group boat 3 and 6 months follow-up compared
Results-clinicaQoL
(13.8 per 100 patyears) in the usuagroup and 36 dea(10.1 per 100 patyears) in the disemanagement groover the 1-year speriod (differenceper 100 patient-y95% CI, 21.4 to 80.09)
ve-
e
oth
d
(i) Significant impment in GI symptseverity in the IBSschool group versguidebook groupmonth follow-up (vs. – 13; p=0.04)
al and Results-hecare use
tient-al care aths tient-
ease oup study e, 3.7 years; 8.8; p=
the mean cumulative frequency ofCOPD-relatehospitalizatioand ED visits0.82 per patiin usual care0.48 per patiin disease managemen(difference, 095% Cl, 0.150.52; p= 0.00 (ii) Disease managemenreduced hospitalizatiofor cardiac opulmonary conditions otthan COPD 49%, hospitations for all causes by 28and ED visitsall causes by(p=0.05 for a
prove-tom S sus the at 6-(– 32 .
NR
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
f ed ons s wasient e and ient
nt 0.34; 5– 01)
nt
ons or
ther by alliza-
8%, s for y27% all).
disease manament programfor patients wisevere COPD
significantly reduced the composite frequency of Chospitalization
emergency vis41% at 1 yearfollow-up. Patpopulation mabe generalisaball were vetera
A structured pgroup educati
superior to wrinformation to enhance knowledge of IBS, a
192S
on of T for
aking
age-mme
ith D
COPD ns and
sits by r ient
ay not ble as ans.
patient on is
itten
w-and
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
single site
Rosal et al 2011
USA
5 sites
Type 2 Diabetes
92S
f c e
Population andparticipants
Patients ages 170, and with IBSaccording to theRome II
s Total: n=252
Latinos en Contintervention (LE=124
Usual care (UC=128
Setting: commuhealth centres
Latino ethnicity,age ≥18 years, diagnosis of typdiabetes; last HbA1c (previoumonths) ≥7.5k; type 1 diabetes
d Intervention
8-S e
nursing and it wperformed with cognitive–behavioural
approach
trol ECI)
)
unity
,
pe 2
s 7 no or
Literacy-sensitivculturally tailorediabetes self-management intervention.
LECI consisted12 weekly and 8monthly sessionand targeted knowledge, attitudes, and smanagement behaviours. It usocial cognitivetheory as a framework. Addressed literaneeds by engag
Control
was a
symptoms, treatment
options, food-related issues, as well as psychological
and lifestyle factors
ve, ed
of 8 ns
self-
uses e
acy ging
Participants in the usual care condition received no intervention
Chronic car
Time of follow up and main study measure
specific anxiety, satisfaction
12 months
HbA1c change, diabetes knowledge, blood glucose self-monitoring, self-efficacy
e
Results-self-efficacy/self-care/knowledge
with baseline (p<0.001 for all comparisons).
The intervention resulted in significachange differences (i) diabetes know-ledge at 12 months = 0.001) (ii) self-efficacy (p =0.001) (iii) blood glucose self-monitoring (p =0.02) (iv) diet, including dietary quality (p = 0.01), kilocalories consumed (p< 0.00percentage of fat (p0.003), and percen-tage of saturated fa(p = 0.04).
Results-clinicaQoL
(ii) Significant redtion in the severitGI-specific anxietthe IBS school grthan in the guidegroup, both at 3 (vs. 1; p<0.001) amonths ( – 5 vs. –p=0.02).
nt in
(p
=
1), p = -
at
Significant differeHbA1c change bethe groups was observed at 4 mo(intervention −0.8versus control −0p< 0.01), althougdifference decreaand lost statisticasignificance at 12months (interven−0.46 versus con−0.20, p= 0.293).No significant intervention effeclipids, blood presweight, or waist circumference Both groups showsignificant increamedication intens12 months
al and Results-hecare use
duc-ty of ty, in roup book ( – 5 nd 6 –1 ;
ence in etween
onths 88 0.35, gh this ased al 2 tion
ntrol .
cts on ssure,
wed ses in sity at
NR
ealth Interpretatiovalue of RCTdecision ma
improve GI symptoms andspecific anxietIBS patients amonths , 3 mopost interventiHowever majothe participantwere from secondary andtertiary care, hresults cannotgeneralised foIBS patients
This culturalltailored intervention improved shoterm clinical outcomes in diabetes conamong low-inminorities. Sereported (dieglucose self-monitoring) mhave favoureintervention gA short term on HbA1c is noted. .
169
on of T for
aking
d GI-ty in
at 6 onths ion. ority of ts
d hence t be or all
y
ort
trol ncome elf-t and
may ed the group effect still
170
Reference,
country,
N of sites
Type ofchronicdisease
Sun et al 2010
China
single site
Asthma
Wakabayashi et al 2011
Japan
chronic
obstructpulmonadisease (COPD)
f c e
Population andparticipants
history of ketoacidosis, lowincome
Total: n=374
Intervention =22
Control =146
Setting: asthmahospital
Aged 18-70 yeawith establisheddiagnosis of asthma
tive ary
Total: n=102
integrated care (group I) =52
Usual care (groU) =50
d Intervention
w subjects in activities such afoods bingo, cooking lessonsusing a step counter, glucosmeter.
28
a
ars, d
education and psychological counselling. Ov2 week period,
asthma educatidelivered in groof 20 in four 1 hsessions, then aindividualised smanagement pdeveloped for epatient. Psychological counselling wasconducted by clinical psychologists in1 hour sessions
up
Group I underwa programme oeducational sessions for 6 months and the
repeatedly recean individually
Control
as
s,
se
ver a
on oups hour a
self-lan
each
s
n six s
conventional
pharmacotherapy for asthma
went of
en
eived
Education was based on
the six domains of LINQ and performed by the same
Chronic care
Time of follow up and main study measure
2 weeks, and 3 months
QoL, asthma-knowledge score, Psychological distress, patients’ understanding of
asthma
6 months, and 12 months
total Lung Information Needs Questionnaire
e
Results-self-efficacy/self-care/knowledge
Significant improvement in asthma knowledge intervention vs cont(p<0.001) immediately after intervention, and 3 months after intervention (p<0.001)
(i) At 6-month evaluation, the meatotal LINQ score forgroup I significantlyimproved (p< 0.02),including understanding of COPD and avoidance of exace
Results-clinicaQoL
in trol
(i) Mean QoL scointervention was compared with cogroup immediateintervention (p<0and 3 months aftintervention (p<0 (ii) significant lowscores for mean of mood state in intervention vs co(p<0.001) immedafter interventionmonths after intervention (p<0
an r ,
nd-
er-
(i) Significant impment was noted iseverity of dyspn(by Medical ReseCouncil DyspnoeScale, MMRC) atmonths comparethe base-line in g
al and Results-hecare use
ores in higher ontrol ly after .001), er .001).
wer profile
ontrol diately , and 3
.001)
NR
prove-in oea
earch ea t 12 d to
group I
There were nsignificant changes in tfrequency ofemergency vfor either groNo hospitaliztions were no
KCE Report 1
ealth Interpretatiovalue of RCTdecision ma
An educationand psycholointervention dimprove asthpatient’s knowledge aQoL. The effefrom each intervention tare not repormaking it diffto determine relative effecfrom educatiocounselling.
no
he f visits oup. za-oted
Integrated carfocused on painformation nefor self-managment in older patients with Ccan improve p
192S
on of T for
aking
nal ogical did
hma
nd ects
type rted ficult the
cts on or
re atient eeds ge-
COPD patient
KCE Reports 19
Reference,
country,
N of sites
Type ofchronicdisease
single site
Watson et al 2009
Asthma
92S
f c e
Population andparticipants
Setting: secondreferral clinic
Aged >65 yearswith history of cigarette smokin(including both current and formsmokers); clinic
course, symptomand laboratory dhad to satisfy th
criteria for the clinical diagnosCOPD, includin
airflow obstructiassessed by pulmonary func
tests with post-bronchodilator inhalation.
Total: n=398
Intervention =20
Control =197
d Intervention
ary
s;
ng
mer cal
ms data he
is of g
ion
tion
tailored educatiaccording to theLung Informatio
Needs Ques-tionnaire score (LINQ)
01
Intervention
group participatin a small-groupinteractive prog
Control
on e on
nursing team that taught group I.
ted p,
gram
Usual care recommended by their primary care
Chronic car
Time of follow up and main study measure
score, Activities of daily living scores, dyspnea score and the BODE index, frequency of hospitalization
12 month
visits to the
e
Results-self-efficacy/self-care/knowledge
bations (p< 0.01 anp< 0.02, respective-ly). No changes weobserved in group U (ii) The total LINQ score at 12 months significantly improvefor group I compareto the baseline (p< 0.03), whereas a decline was noted for group U (p< 0.05At 12 months, the twgroups showed a significant differencin total LINQ score(p= 0.003)
NR
Results-clinicaQoL
d -re U.
ed ed
5). wo
e
(p< 0.01), whereagroup U showed significant worseMMRC at 12 mon(p< 0.03). (ii) BODE (body mindex, airflow obstion, dyspnoea anexercise capacityindex scores in gwere significantlyimproved at 12 mcompared with thbaseline (p< 0.02whereas they wesignificantly worsin group U (p< 0. (iii) ADL (Activitiedaily living) was improved in groumonths (p< 0.03)remained stable amonths (iv) There were nsignificant changthe total SGRQ (SGeorge’s RespiraQuestionnaire (Sin either group In both the controintervention grouobserved significimprovement in toscores on the Pe
al and Results-hecare use
as a ning in nths
mass struct-nd y) roup I
y months he 2), ere sened 03).
es of
p I at 6 ) and at 12
no es in St atory
SGRQ)
in group I duthe initial 6-mperiod (p< 0however, thewas no signidifference between thegroups durinfollow-up pe
ol and ps, we
cant otal
ediatric
(i) The numbvisits to the Edecreased ingroups but significantly
ealth Interpretatiovalue of RCTdecision ma
uring month .04); ere ificant
ng the riod
information neand health outcomes in medium to lonterm.
Caveat in the interpretation health care usemergency visand n hospitalizationwere very low
ber of ED n both
Education aboasthma in a smgroup, interacformat, signific
171
on of T for
aking
eeds
ng
of se: n sits
ns w
out mall-
ctive cantly
172
Reference,
country,
N of sites
Type ofchronicdisease
USA
single site
Wearden et al 2010
U.K
186 sites
Chronic fatigue syndrom(CFS)
f c e
Population andparticipants
Setting: univershospital.
Aged 3–16 yearhad physician-diagnosed asthm
and had requirevisit to the ED foacute asthma during the recruitment pha
me
Total: n=296
Pragmatic rehabilitation (P
=95
Supportive liste(SL) =101
General practitioner treatment as us(GPT) = 100
d Intervention
sity
rs,
ma
ed a or
ase
of education abasthma, and targeted to eithethe parent or thchild, or both, depending on thage of the child
PR)
ning
sual
PR: A programmof graded returnactivity is desig
collaboratively bthe patient and therapist on thebasis of a
physiological dysregulation model of CFS/M
Control
bout
er e
he
physician.
me n to ned
by the
e
ME.
Usual care: GPs were asked to manage their
cases as they saw fit, but not to
refer for systematic psychological
therapies for
Chronic care
Time of follow up and main study measure
emergency department, use of oral corticosteroids, pediatric asthma
quality-of-life, caregivers’ quality of life
Assessed at entry to the trial (week 0), after treatment (week 20), and one year after finishing treatment (70 weeks from recruitment).
Fatigue and physical
e
Results-self-efficacy/self-care/knowledge
Compared with patients allocated to GPT, PR patientshad significantly improved fatigue (treatment effect estimate −1.18, 95%CI: −2.18 to −0.18; p=0.021), ansleep (−1.54, −2.96−0.11; p=0.035) at20 weeks.
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Asthma QoL Questionnaire during the year aenrolment.
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Compared with pallocated to GPTpatients had signcantly improved depression (treateffect estimate (−−2.16 to −0.20, p=0.018)
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functioning
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e
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However at 70 weeThe difference was no longer statisticalsignificant (−1.00, −2.10 to +0.11; p=0.076) (ii) Patients who received SL had significantly worse physical functioning at 20 weeks than patients who had GPT (−7.54, −12.76to −2.33; p=0.005); but at 70 weeks PRpatients did not differ significantly inphysical functioningfrom GPT (effect +2.57, 95% CI: −3.9to 9.03; P=0.43) (i) WEB-SM group demonstrated statistically significant improvement in physical functional status compared to standard care only(F(1,115)=5.08, p<.03). (ii) General
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KCE Reports 19
3.5.5. SearchThe table belowMedline. The search straRCTs are availa
Date
Database
Search Strategy
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ent adj educationname of substancol supplementaryry concept, unique
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for systematic rev
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s & Other Non-R) <1946 to Prese
n).mp. mp=title, ace word, subject y concept, rare e identifier * or reliance or effabstract, originsubject heading
oncept, rare e identifier
mp=title, abstract, d, subject headinoncept, rare e identifiermp. mp=title, ace word, subjecty concept, rare e identifiernt).mp. mp=title, ace word, subject y concept, rare e identifiermp. mp=title, ace word, subject
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abstract, heading disease 70279
fficacy or nal title, g word, disease 72573 original
ng word, disease 24845 abstract, heading disease 14605 abstract, heading disease 6319 abstract, heading
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word, protocol supplementary c8 ((self oprogramme).mpof substance wsupplementary concept, unique 9 (self adoriginal title, namword, protocol supplementary c10 or/1-9 11 *Cardiov12 *Hyperte13 *Heart F14 *Myocar 113808 15 *Stroke/16 *Neurod17 *Depress18 *Psycho19 *Schizop20 *Mental 21 *Asthma22 *Pulmon 13515 23 *Arthritis24 *Emphys25 *Fibromy26 *Fatigue27 *Irritable
supplementary cconcept, unique idor patient) adj2. mp=title, abstra
word, subject heconcept, rare diidentifier 13
dj monitoring).mpme of substance supplementary c
concept, unique id120674 vascular Diseasesension/ 125814 Failure/ 53494 rdial Ischemia/or
33028 egenerative Diseasion/ 35634 tic Disorders/ 20phrenia/ 57880 Disorders/ 8
a/ 76769 nary Disease,
s/ 15279 sema/ 3064 yalgia/ 4455
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concept, rare disdentifier 712 management act, original title, neading word, proisease suppleme38 p. mp=title, absword, subject he
concept, rare disdentifier 58
s/ 54128
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0648
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175
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adj2 name otocol entary
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176
28 *Obes29 exp R30 long-t31 (chronoriginal title, nword, protocosupplementar32 (chronoriginal title, nword, protocosupplementar33 or/11-34 ((patiemp=title, absword, subjecconcept, rareidentifier 35 10 or 36 33 an37 Meta-38 meta 39 metaa40 Meta-41 (syste 3195842 exp R43 or/37-44 cochr45 emba46 (psyc47 (psyc
sity/ 69760 Rheumatic Diseasterm disease.mp.nic adj2 diseasename of substancol supplementaryry concept, uniquenic adj2 care).name of substancol supplementaryry concept, unique-32 111354ent or self) astract, original titct heading word, e disease supplem
604 34 121027
nd 35 18988 -Analysis as Topicanaly$.tw. 38958 analy$.tw. 1081 -Analysis/ 30865 ematic adj (revie8
Review Literature a-42 80559 rane.ab. 19229 ase.ab. 16652 hlit or psyclit).ab.hinfo or psycinfo)
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or cinhal).ab. 63citation index.ab.309 t.ab. 519 31005
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search$.ab. 167 19276 n criteria.ab. 14raction.ab. 72 21054
1647579 62 13702 nt/ 483047 743681 / 296404 or 58 or 63 10
6 1140449 8 97596 69 574 alth Literacy/ 56es Mellitus/ 55 1161782 121397
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Chronic car
1
2
3
4
5
6
7
8
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009;30(4):550-4.Park MS, Kim TN,s Chronic Diseasternet. Diabetic M
er AK, Song J, RYour Healthcare in
illnesses. Pat2):207-13.
Moore-Hill M, Frelf-management
ed controlled trial.CA, Peterson MG
niker LA, et al. Ament education fo
nt. Annals of EmeRLH, Iris MA, Bod
ne mind-body intrnal of Pain. 2009;S, Leigh Packer gue self-managemcal conditions: aation. 2010;24(8):7ashi R, Motegi T,l. Efficient integra
ohnson DM, Baueestive heart failure:158-65.
Z, Scanlon K, Bryolled trial of a
for chronic oof General Intern
L, Shakibi A. Thon of stroke pat
, Yang SJ, Cho Gse Care system
Medicine. 2009;26ush J, Sklar L, S
ntervention for oldient Education
ranks P. Home-batraining: findin
Ann Fam Med. 2GE, Gaeta TJ, FeA randomized cor asthma patienergency Medicine.e R, Drengenbergtervention for old;10(1):68-79. T, Passmore AE
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KCE Report 1
er RL. An intervee. American Journ
ant Shilliday B, Dliteracy-sensitive
obstructive pulmonal Medicine. 20
e efficacy of selftients. Saudi Me
GJ, Hwang TG, etusing cellular ph(6):628-35.
Stevens A. Makinder adults with mu
and Couns
ased, peer-led chngs from a 12009;7(4):319-27. ernandez JL, Birkcontrolled trial of nts in the emerg 2011;57(6):603-1g C. The effective
der adults with ch
E. Effectiveness ofor people with ch
ontrolled trial. Cl
i T, Jones RC, Hfor older patients
192S
ention nal of
Dewalt self-
onary 12;27
f-care edical
t al. A hones
g the ultiple
seling.
hronic -year
khahn self-
gency 12. eness hronic
of an hronic linical
yland s with
KCE Reports 19
chronicNeeds 2011;1
67. WeardeRK, Pepatientsrandom
68. BucknaM, et apatientstrial. BM
69. Rice KLet al. pulmonof resp
70. Sun HWEffect oof life o
71. WatsonMP, etasthma2009;18
72. Baker DomingeducatiknowleJourna
73. BosworSK, et control Americ
74. BosworBJ, ethyperteMedicin
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c obstructive pulmQuestionnaire.
1(4):422-30. en AJ, Dowrick C
eters S, et al. Nurss in primary
mised controlled trall CE, Miller G, Lal. Glasgow supps with moderate MJ. 2012;344:e10L, Dewan N, BlooDisease manag
nary disease: a rairatory and critica
W, Wang JP, Wanof educational anof asthmatic patienn WT, Gillespie Ct al. Small-groupa control by 81(5):257-63. DW, Dewalt DA,go K, et al. The eion and counselindge, self-care bl of Cardiac Failurrth HB, Olsen MK
al. Patient edublood pressure ian Heart Journal.rth HB, Olsen MKt al. Two self-ension control: ane. 2009;151(10):
monary disease usGeriatrics & g
C, Chew-Grahamse led, home bascare with chro
rial. BMJ. 2010;34Lloyd SM, Clelandported self-manag
to severe COPD060. omfield HE, Grill Jgement program ndomized controll care medicine. 2ng SZ, Wang YY, d psychological innts. Respir Care. 2
C, Thomas N, Filu, interactive educchildren and
Schillinger D, Heffect of progressng versus brief edbehaviors and hre. 2011;17(10):78K, Dudley T, Orrcation and provn primary care: a 2009;157(3):450
K, Grubber JM, Ne-management ina randomized t687-95.
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m C, Bentall RP, sed self help treatonic fatigue sy40:c1777. d J, McCluskey Sgement trial (GSuD: randomised co
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Hawk V, Ruo B, ive, reinforcing teducational interveheart failure sym89-96. r M, Goldstein MKider decision su
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K, Datta pport to zed trial.
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7
7
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7
8
8
8
8
e
75. Luciano JR, Garciapsychoedupractice foClinical Jo
76. OerlemanSpreeuwebehavior iJournal of
77. Rosal MCet al. Randiabetes latinos en
78. Powell LHLeon CF, with hearrandomize
79. Williams DInternet-encontrolled
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81. Barlow J,controlled sclerosis.
82. Cadilhac Osborne randomizeprogram. S
83. Chan SWpsychoedu
V, Martinez N, Pa-Campayo J, Vucational treatmeor fibromyalgia p
ournal of Pain. 201s S, van C
enberg P, van Dun irritable bowel sf Psychosomatic R
C, Ockene IS, Resndomized trial ofself-managementcontrol. Diabetes
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MT, Fernandez-Val. Effectiveness plemented in ge
omized controlled
O, Herremans ning on cognitionssibility trial using P0(3):267-77.
MJ, Borg A, Olendztive, culturally ta
or low-income la):838-44. Janssen I, Mende
counseling in paerence and rete4(12):1331-8. , Sheth M, Clauwyalgia: a random
Rosen SN, Heitkefor irritable b
s. combined in-pel of Gastroentero
ist M. A randomor people with mu. 2009;77(1):81-9
Lindley R, Lalocentered, single-oke self-manage
am W. Evaluationnts with schizoph
181
Vergel of a
eneral trial.
P-J, s and PDAs.
zki B, ilored tinos:
es de atients ention
w DJ. mized
emper bowel erson ology.
mised ultiple . or E, -blind, ement
n of a hrenia
182
and the2009;75
84. Chen Sof self-diseaseDialysis
85. Chow Sundergmanage2010;66
eir family caregiv5(1):67-76.
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vers. Patient Ed
CY, Wu IW, Lee pport on the proge randomized co. 2011;26 (11):356
Y. Health-related dialysis: effects
mme. Journal o
ucation and Cou
CC, Wu MS. Theression of chronicntrolled trial. Nep60-6. quality of life in
s of a nurse-leof Advanced
Chronic care
unseling.
e impact c kidney phrology
patients ed case Nursing.
8
8
e
86. RingstromSimren MinformatiosyndromeGastroent
87. Saksena hypertens2010;69(2
m G, Storsrud S, M. Structured pa
n in the manage: a randomized terology & Hepato
A. Computer-bion: A systemat
236).
Posserud I, Lundtient education ement of patientcontrolled study.
ology. 2010;22(4):based educationtic review. Healt
KCE Report 1
dqvist S, Westmais superior to wts with irritable b
European Journ420-8.
n for patients th Education Jou
192S
an B, written bowel nal of
with urnal.
KCE Reports 19
4. ORGABELGCOORSTRUC
4.1. Stake(micro
Stakeholders m
Sessions Flan
Micro/meso lev
Patient aninformal carerepresentatives
Pharmacists organisation
Hospital Specialist
Representatives
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ANISATIONIUM: SWO
RDINATIONCTURES/Pholders consul
o and meso levmicro and meso
ders, 17/04/2012
el Name
nd rs
Lamers Hilde
Sofie De Mars
Haems Marleen
Marina Lermytte
Frank Nobels
Paul van deHeuvel
s Bart Coessens
N OF CHROT ANALYS
N PROGRAM
ted during braivel)
level
2 & 26/04/2012
Function Director VlaamTurnhout
Staff Christelijkcoördination ZiCaregiver OrgaKoninklijke OApothekersgiDirector DepaManagementDe VolksmacProject leadede thuiszorg.”
s EndocrinologVlaams TijdsVlaamse Diab
en Cardiologist ZAntwerpen maker van kliLOK verantwo
s Director Bewo
ONIC CARESIS AND
MES instorming ses
mse Alzheimer Liga v
ke Mutualiteiten ekenzorg CM, Infor
anisation (Mantelzoost-Vlaams ld artement Professi, KOVAG
cht Turnhout r “Medicatie op m” ist OLV Ziekenhuschrift voor Diabbetes Vereniging Ziekenhuis Netwe
nisch pad hartfaleoordelijke cadioloonerszorg
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sions
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rmal rg)
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uis Aalst betologie
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of esting/nursing
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General Practice Nurse
Representative of regional care organisations
cro and meso lev
rs, 17/04/2012 &
Johan Abrahams
Jannie Van Hespel
Louis Paquay
Tine De Vlieger
Karin Van Sas
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Ingrid Druyts
vel
26/04/2012
St Bernardus nu
Director St Elisabeth WoHasselt. Nationaal VerboMutualiteiten Deputy director Gezondheid en Whomecare (thuisNurse coordinathomecare (thuisCoordinator PallAntwerpen (netwzorg region AntwNurse in GP groand Diabetes edNurse in GP gro
Coordinator SamenwerkingsEerstelijnsgezonAmberes AntweCoordinatorMultcooperation - ZoZuiderkempen Lokaal Multidisc
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on- en zorgcentru
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szorg) iatieve Hulpverlen
werk voor palliatiewerpen) oup practice Baarlducator oup practice Deurn
initiatieven ndheidszorg(SEL)rpen tidisciplinary orgtrajectpromotor
ciplinair Netwerk
183
m
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r
184
Stakeholders m
Sessions Flan
Hospital Manage
GP organisation
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micro and meso
ders, 17/04/2012
Ilse Pynaert
er Geert Debbaut (noattending)
n Jos De Smed
Patrick Verdonck
Kristien VaDeyk
level
2 & 26/04/2012
ZuiderkempeVerenigde HuZuiderkempeCoordinator,zof local multidMeetjesland
ot Director AZ T
dt GP BooischoCRA RVT HeVoorzitter RaVELO (Vlaamlid Raad van lid Raad van ThuiszorgoveGeneral practCoordinatorSEerstelijnsgezGent
an UZLeuven caNurse specia
n, uisartsenkringen n
zorgtrajectpromotodisciplinary netwo
Turnhout
t eist-op-den-Berg ad van Bestuur va
ms EerstelijnsoverBestuur Wit Gele Bestuur GDT/SEL
erleg Mechelen titioner
Samenwerkingsinitzondheidszorg (S
ardiology list
Chronic care
or head rk
an rleg)
Kruis L
tiatieven SEL)
e KCE Report 1192S
KCE Reports 19
Stakeholders m
Francophone S
Micro/meso lev
Patient informal carepresentatives
Pharmacists organisation
GP organisation
Hospital manag
Hospital special
92S
micro and meso
Sessions, 19/04/
vel Name
and arers
Caroline Du
Sabine Hen
Marlène Clo
Anne (Interviewed
ns Jean Franço
Corinne Boü
Guy Beuken
Saphia Mok
ers Marius Lattending)
Myriam Sero
lists Emmanuel L
Emonts (Inte
level
/2012 & 23/04/201
Fu
ucenne SoAS
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unction
ocial worker, CoordinSBL Aidants proches
esident ASBL Liguezheimer
ce-president Ligue dsuffisants rénaux
ofessor, Clinical phaniques Universitairec
eneral practitioner, porum des Associatioénéralistes ASBL
eneral practitioner Médicale Seraing
eneral practitionerCACL
eneral practitioner Medicale solidarité Ma
x-president of the sociation francopho
recteurs médicaux
ursing director Hôpiterre
neumologist (HENAL
ardiologist, director onique de l'insuffisan
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nator s
e
des
armacist, es Saint
president ons de
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Representatives ofegional care
organisations
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primary carnurses anndependent nurse
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f Mazlum Kara
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of re d
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Christine Ori
Claudine Baud
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cardia
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coordinator of d,transmural care, uesUniversitaires S
l worker, CoordinatoD Conectar
l worker, Coordinatoepatitis C networksels (hôpital St-Pi
e coordinator, Fédéret Soins à Domicile D)
endent nurse, presiAIIB (association o
endent nurses)
dinator of RML-B
185
Saint
or
or of k in erre)
ration
ident of
186
4.2. Stakemeetin
Macro level
Sessions 23/05
Baeyens JePierre
Minne MaClaire
De Ridder Ri
Decoster Christiaan
Borgermans Liesbeth
Quoidbach Vinciane (remplace C. Le
holders consulngs (macro lev
5/2012 & 31/05/2
ean- ObservatorChronische+ StuurgroeConferentie
arie- StuurgroepConferentieZiekten; DG
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ted during stakvel)
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rium voor de e ziekten ep National e Chronische Ziek
p National e Chronische G Santé FWB
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rium voor de e ziekten + p National eChronische abinet Minister
x
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p F
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IsBV(
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m voor de ekten + ational hronische S
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m voor dziekten
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ublique, DG2
ekenhuis Gent
m voor de ekten; Santhea
m voor de ekten raliste -
m voor de ekten+ raliste
m voor dziekten
Nationa
KCE Report 1
d
e + al e
e,
e + al
192S
KCE Reports 19
Pacquay Louis
Weeghmans Ils
Haucotte Geneviève
Schreurs Ferna
92S
ConferentieZiekten+ A
ObservatorChronischeKruis
se StuurgroepConferentieZiekten+ VlPlatform
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and ObservatorChronische
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p National e Chronische laamsPatiënten
p National e Chronische NAMI
rium voor de e ziekten
sche
e
Chronic care 187
188
4.3. Overvsessio
The themes ideSWOT matrix. Subsequently treform proposalanguage.
Theme 1
Seamless care
Strength
Working as a t“Het team moet vopgeleid wordt, dahet goed, we werke
Local organizathe care “Het kort bij elkaar overleg te hebben, is zeker belangrijk. wondzorg ingescha
Patient guider“Kleine ziekenhuizenaar de familie toe,
Structured hos“Ce qui nous aide bconcertation entre llieu où on échange
Coordination m
view of the dataons and de stakentified during the
he information waals. The quotes
e: Continuum of
team for a patienersterkt worden, maan valt en staat het meen als een team rond é
ations who work
zitten van de verschilldit is zeer laagdrempeGoede samenwerking
akeld aan huis (van W
en hebben patiëntenbe, algemene ziekenhuiz
spital-based coobien, à l’hôpital, c’est ule service social et au
e et où on apprend à s
meetings (with S
a collected durikeholders grou
e qualitative analys
as reported in theare reported in
care across lines
nt ar dit moet niet geleet die ene persoon enéén patiënt met de hu
closely together
ende diensten (thuiszelig, het zijn bekende g met verpleegkundige
Wit Gele Kruis).”(B2VL)
egeleiders, er is veel szen hebben dit niet.”(B
ordination to linkune plateforme qu’on amoins les coordinatioe connaître, où on pe
SISD and LOGO-S
ng the brainstoup meetings sis are reported u
e macro level mee the French and
s and within line
id worden door één n dat werkt niet, in eeisarts als centraal per
r and so can guid
zorg, maaltijdbedeling,gezichten. Lokaal nete, er is ook een refere
sneller contact met soB2VL)
k with home-basea appelé ‘Enodios’, qu
ons de soins et de servut aussi dire ce qui ne
SEL) at the patie
Chronic care
orming
using the
etings as d Dutch
es
persoon die daarvooen palliatief team werkrsoon.”(B2VL)
de each other in
rusthuis,…), om twerk dat gekend is. Dentieverpleegkundige
ciale diensten, ook
ed coordinationsui est un lieu de vices de Bxl. C’est un e va pas. »
nt’s life place
e
Weakness
or kt
Dit
s
Shortened ho“Patiënten wordepas te laat thuiszis.”(B1VL)
No coordinat“Wij hebben de pbepaalde medicagebeurd.”(B1VL) “On voit régulièrequi, lorsqu’ils retrdans la continuitéchangements de
Limitation to and GDT) : “C’est bien, mais matinée de consu
Lack of synth“Problème d’infordisponibles, d’où
ospitalisation, unen sneller naar huis georg beginnen organise
tion for the followpatiënt gezien (in ziekeatie te veranderen, ma
ement des patients quransitent dans le milieué, par exemple parce qtraitement qui ont été
the GP Participat
pour un MG, c’est coultation pour y aller, pa
hesis function wrmation, très liée à la fla difficulté pour ces p
nprepared in primestuurd, ook allemaal oeren, we weten het pa
w up of medicatienhuis) en vragen aanaar dat is dan bvb na e
i sont hospitalisés pouu de soins chroniquesqu’ils n’ont pas été bie
é mis en place suite à
tion to coordinat
mpliqué d’y aller, parcarce qu’il faut compter
within the systemfonction de synthèse. personnes d’avoir l’inf
KCE Report 1
mary care op heel korte termijn, jas als de patiënt thuis
ion across lines n de huisarts om een een jaar nog niet
ur un problème aigu pos, il va y avoir un problen informés des leur épisode aigu.”
ion meetings (SIS
ce que je dois annuler r les temps de trajet.”
m Beaucoup de ressour
formation correcte. La
192S
je kunt
our ème
SD
une
rces
KCE Reports 19
“La concertation SI “On a également cointervenants du domentre eux pour voir mieux l’offre de soi
92S
SD est un bel outil po
onfié aux SISD la gestmicile, aussi bien les icomment les choses
ns. Mais donc, on n’es
ur la coordination, ave
tion d’un outil, la concndépendants que les s’organisent sur une zst pas dans une relatio
ec le patient éventuelle
certation MD. C’est surreprésentants de struzone déterminée, pouon directe avec le pati
Chronic car
ement.”
rtout pour les ctures, qui discutent r essayer d’articuler aient. ”
e
au
personne ne sait de gare’).”
The difficultieonly for patie“Er moeten ‘wegwcel, een OCMW, onduidelijk. De hnodig.”(B2VL)
Lack of recog“Voor de huisartsziekenhuis om ee “La communicatiomanière non orgal’apprend souven
Disease-orie“Je ne suis pas sc’est que c’est uthospitaliers : le cetrajets de soins, cinsuffisant rénal e
The lack of lack of antici“De huisarts is vostructureren. We moeten reageren
Guidelines apsychosocia« Cette dame estmange pas tous l
parfois plus elle-mêm
es to find your wents but also for wijzers’ komen in het ber zijn zoveel mogelijk
huisarts kan doorverwi
gnizable contacts is het niet gemakkelijen plan te bespreken,
on et l’échange d’inforanisée – le MG n’a pant longtemps après.”
nted coordinatiouper-enthousiaste parilisé sur une pathologientre de la ménopauscomment va-t-on faire et hypertendu ?”
proactive plannpation or avoidin
ooral opgeleid om creahebben pro actieve c
n op acute situaties.”(B
and protocols aral issues t très débrouillarde, mles jours et elle mange
me à quels services elle
way in the health health professio
bestaande zorgaanbokheden, maar nu het iijzen naar dit loket. Ja
t person across ajk om te weten wie heeen aanspreekpunt o
rmation, vu que ça se s décidé d’organiser u
on r rapport aux trajets deie et ça me fait penser
se, le centre de ceci etpour la personne qui
ning and workingng of acute episoatief, probleemoplossehronische zorg nodig
B2Vl)
re very biomedi
ais elle ne choisit pas e ce qu’il y a au SAMU
e fait appel (image du
care system, noonals d, dit kan een loket zijs allemaal een beetje
a zo’n wegwijzers zijn z
and between lineet contactpersoon is in ntbreekt.”(B2VL)
passe dans l’urgenceune hospitalisation-, le
e soins, ce qui me faitr à ces pseudopodes t cela. Si on multiplie lest à la fois diabétiqu
g goal oriented,odes end te werken,minder in plaats van telkens t
cal oriented, lac
ce qu’elle mange. EllU social. Ici, on oublie
189
‘hall
ot
jn, een
zeker
es het
e et de e MG
t peur,
es e,
, and
om te te
ck of
e ne les
190
Threat Pillarization ofbetween differ“Il y a une multiplicaau niveau communSISD deviennent l’odes coordinations r
f networks, culturent decision leveation de projets similaautaire, au niveau régorgane qui va centralisrattachées à des organ
ural influence on el (region, provin
aires : on fait de la prévgional, au niveau fédérser les finances, ce qunismes assureurs, il y
organization, conce, federal...) vention pour le diabèteral …. On gaspille beaui serait une bonne chaurait nettement moin
Chronic care
ompetition
e au niveau provincialaucoup d’argent. Si leshose, au lieu d’avoir ns d’injustice sociale.
e
guidelines diététiq
Carepaths ar“Er is niets is vooaandoening. Zorgaandoening.(B1V
Too many hedifferent tycoordination“Er ontstaat een swerken: hiervoor kennen en herke1persoon samenwTeveel brengt ee “Pour Bruxelles, ocoordination et lacoordination que
Lack of a coo“De zorg rond de daarvoor opgeleidover het medischniet de spilfiguur
l, s
Opportunities
ques, dans ce cas, ça
re not initiated soorzien voor dergelijke pgtrajecten starten pas VL)
ealthcare profesypes of “coor) spanningsveld doordais er een aangepaste nnen. De vraag kan gwerken zonder de trapn aantal gevaren met
on a une vingtaine d’ina concertation autour d
d’intervenants tout co
ordinator for the patiënt zou toch geco
d wordt. Hij moet een he, maar ook over de pzijn.(B2VL)
a ne sert à rien. »
oon enough patiënten met een begin een heel laattijdig s
ssionals around rdination struc
at we met veel hulpverattitude van een ploe
esteld worden met hoppers te verliezen, ookzich mee.”(B1VL)
nstitutions compétentedu patient. Il y a plus dourt autour d’un patien
individual care ooördineerd moeten wooverzicht hebben ove
psychosociale problem
KCE Report 1
ginnende chronische stadium van chronisch
a patient. Too mctures” (fragme
rleners rond 1 patiënt eg nodig: en ook grenzoeveel mensen mag jek voor de patiënt zelf.
es pour faire de la d’intervenants faisant dnt”.
of a chronic patiorden door een persooer het geheel en niet pmatieken,.. de huisarts
192S
he
many ented
zen e rond
de la
ent on die
puur s kan
KCE Reports 19
Ce serait plus facileassureur. » (B1FR) Lack of clear b“Il peut aussi y avoavec des missions Tension betweand choices of“ Dans cette situatiovoulait pas d’aide fa Lack of mutua« Il y a parfois des que si on s’adressecoordination. Il y a
4.3.1. Reformcare techronic
People with cconsisting of aa multidisciplinclose collaborof the “refere“case managereinforce the f(home-based) view, not onlypsychological,• There is a
and mainlycomplex ne
92S
e si les coordinations n)
boundaries of heir un sentiment de conpeu claires. » (B1FR)
een the prioritiesf the individual pon, la dame a acceptéamiliale. » (B1FR)
al knowledge betwhiatus entre les MG et
e à une coordination dencore de la méfiance
m proposal 1: A eam is at the cenc care needs chronic care nea range of care pinary primary carration with the Gent health care per”, see proposafirst line of care and teams from
y biomedical nee, social and psycneed for a clear
y defining chronic eed)
n’avaient pas d’étique
ealth care organizncurrence qui s’établit
s of care givers opatient é le principe d’une aide
ween hospital ant les centres de coorde soins, que tous les
e par rapport à ça. »
polyvalent multnter of a system
eeds should beproviders. This sre team, with the
GP and helped byprovider” (who wal 2), as a dyadand the dialogu
m the institutionaeds will be takenchosocial needs definition of chropatient in relation
tte, les rattachant à un
zations , par une mauvaise ré
or coordinators a
e familiale. Parce qu’a
nd coordination ination de soins parceprestataires devront fa
tidisciplinary primcaring for peop
e cared for by should be organ
e patient at the cey coordination anwill thereafter bed. This team is
ue between primaal-hospital secton into account, b
and preferencesonic care as startin to their needs (s
Chronic car
n organisme
épartition des tâches,
and the priorities
au début, la dame ne
centres e qu’il y a encore l’idéeaire partie de cette
mary ple with
a team nized as enter, in nd work
e named vital to
ary care r.In this but also s. ng point imple vs
e
s
e
o Overconsshooting”
o The quesor not, dethe peopl
o The issuestepped ccomplex mentione
“Wanneer beszorg patiënt meerdere perdag nodig heemultidisciplinasysteem zijnintervenanten
“Je kan daachronische pa
sumption: a lack” of care. This migstion is not whethepending of the tyle with chronic nee of the case macare approach, thcases. Otherwis
ed here above
schouwen we nu is? Dit hebben
rsonen noodzakeleft (bijv voor hogair team, dat zou ‘. Voor chronisc
n nodig zijn.”(SGM
ar een antwoordatiënt, zorg op he
k of prioritizationght be a financial bher a multidisciplinype of need. Thaed but act accord
anager should behe case managerse, this may lead
eigenlijk dat een pwe nodig om t
lijk zijn, want iemae bloeddruk), hee‘overshooting’ zijnhe zorg, moete
M1)
d op geven dooret laagst mogelijke
may lead to “Oburden nary team should
at team should beingly to the needs
e more prioritizedr should focus in d to the oversho
patiënt een chronte weten wanneand die één pilletjeft geen nood aann. Dit zou geen effn er meer dan
r ‘stepped care’ e en efficiënte ma
191
Over-
exist e near s. . In a more
ooting
nische er er je per n een ficiënt één
voor anier,
192
… we hebeerste lijnmultidiscipl
• There is als“coordinatio
“Il faut clareference, de la situat
• The issue specific heBelgium fo
“Voor mij iscentrum stin het middmaar de gl
• The multidorganizatio
“L’aspect Mest très copeut auss(SGM2).
• Patient sho
“Ik mis nopatiënt wilwant dat iszonder uw
“De patiëndaarond ee
• Patient shoalso about
“Er is gebreals een tea
bben er alle belan een team optlinair team.” (SGMso a need for a clon”, “referent hea
arifier les mots ce n’est pas clair.tion actuelle ou biof multidisciplina
ealth problem (for r obesity) or as a
s het niet belangrtaat, maar het is bdelpunt staat, en hlobale organisatie isciplinary team s
on, but also by the
MD doit interveniromplémentaire pasi être le diagno
ould be at the cen
og iets heel essellen zien en zijn s echt wel essentpatiënt erbij , dan
nt zou in het miden eerstelijnsteamould be clear abowho does what in
ek aan synthese bamspeler, als een
ang bij voor chrotreedt en daar M1) ear definition of s
alth care manager”
‘coordination’, ler. Parle-t-on de la ien de ce qu’on sory team needs toexample, has begeneric primary c
rijk of de eerstelijnbelangrijk dat de hierin heeft de eer is het allerbelangshould not only be diagnostic
r dès le diagnostar rapport au diagostic psychologiq
ter of this multidis
entieels. Ik zou ionmiddellijke ve
tieel, als je een mn ben je verkeerd
dden van het sysm” (SGM2) out the fact that hen the team
binnen een team. n patient die door
onische zieken daheb je nood a
ome central conc”…
eadership, persomême chose ? P
ouhaite ? » (SGMo be clarified: foceen done in somecare team
n of het ziekenhuorganisatie in zijnrstelijn een belanggrijkst.”(SGM1) be concerned by t
tic : le diagnostic gnostic médical (…que, le diagnosti
sciplinary team
in die statement erzorgers, mantelmultidisciplinair tebezig.”(SGM1)
steem moeten st
e is cared by a te
De patient is nietr een team verzrg
Chronic care
at in de aan een
cepts like
onne de Parle-t-on M2)
used on e area in
uis in het n geheel grijke rol
the care
infirmier …) et ça ic MD »
ook de lzorgers, am hebt
taan, en
eam, but
t gekend gd wordt.
•
•
•
•
e
Patient moet positieve con‘marketen’ vawerkt al seenop het juiste mteam kunnen
It should be mplay a leadingline of care
“Cette équipeligne et le secsimple créatiofaut plus que
However wordone by lookiand primary ccentrism)
“Mijn belangrcentrisme hebgaan vervalleis het allerbebelangrijk is. eerstelijn.“(SG
“Wat bedoel worden, het gkortverblijven
Chronic care c
“Er is enormgenerieke voowaarin het ge
Information mlocallevelis oft
een label krijgen,nnotative moet
an het teamaanpan team, die zorgt moment, en moetingeschakeld wor
more emphasized g role in structuring
e doit renforcer lecteur de deuxièmeon de ces équipesmettre les équipeking on a primarying at the best eqcare (not falling in
rijkste opmerkingbben gewerkt datn in het andere eelangrijkste de g Maar wel met
GM1)
je met ‘institutigaat niet enkel ozijn”. (SGM1) comes in a divers
m veel te doen roorstellen, het zalïmplementeerd wmeans about wten lacking (threa
, met daarbij het krijgen, moet o
ak. De patient modat hij bij de juistt hun advise kunnrden” (SGM2) that primary careg the dialogue be
e dialogue entre e ligne, mais je nes va renforcer le des en place” (SGMy care multidiscipquilibrium between primary care- c
g is dat we lat was fout maar wn louter eerstelijngeïntegreerde sat een belangrijke
ionalised care’, om ziekenhuizen,
se health landscap
ond ‘lokaliteit’, ol altijd afhankelijk
wordt.”(SGM1) what does exist
t)
KCE Report 1
feit dat deze labeook helpen vooroet weten dat het te person terecht nen geven rond w
e multidisciplinary tween first and se
les soins de preme vois pas comme
dialogue. Je penseM2) plinary team shoun institutionalized
centrism after hos
ng van uit hoswe moeten nu ookn werken maar voamenwerking die e aansturing vanu
dit moet verduidmaar dit kunnen
pe (threat)
ok al komen wek zijn van de lok
as services at
192S
el een r het team komt
wie de
team econd
mière ent la e qu’il
uld be d care spital-
spitaal k niet or mij
heel uit de
delijkt n ook
e met kaliteit
t the
KCE Reports 19
“Souvent, lqui sont disne sont sode clarté su
“Il faut qusoutiennenexistent su
• The role of
“Le MG accompagnun travail e
“Il faut quedépensera essentielle
“Il faut auspeut idennécessaire
“De huisartaken heeftis vandaag(SGM2)
“ L’AR 78(SGM2)
• There arebetween phave a ceaccount wh
“Je moet dvertrekken overspant.
“J’entends délèguent l
92S
le médecin générsponibles au sein
ouvent pas mises ur ce qui est dispo
’il y ait des équint le MG au niveaur le terrain” (SGMf the GP
peut être la pné de quelqu’un.
efficace” (SGM2)
elqu’un qui coord moins et pourras qui lui seront rap
ssi un case manantifier les difféement outillé ou qu
rts deze taak nieft, en de organisatg een manager o
8 ne dit rien du
different visionsrimary and secon
entral position. hen posing this sta
de stelling meenvanuit het zo
”(SGM1)
des choses difles tâches et de t
raliste n’a pas unede sa région ou den valeur. Il y a
onible” (SGM2)
ipes sur le terraiau de l’informatio
M2).
ersonne de réfC’est en équipe à
donne la fonction a se préoccuper ppportées par les g
ger pour aider le rents besoins, ui n’a pas le temp
t kan opnemen, tie hiervoor zo verop die plaats te z
rôle du MG con
s and opinions ndary care in ourThese views wilatement (threat)
emen dat er ookorgcircuit die h
férentes : vous ptravailler en duo. C
e idée de toutes lede sa commune. Cun souci d’inform
in en première lion sur les possibi
férence, mais dà deux qu’ils peuv
de chacun, et leplus de certainesgens du terrain” (S
médecin généralmais qui n’e
ps” (SGM2)
omdat hij zoveelrscheiden is. Ons zetten, zou dit zin
ncernant la coord
on the task der country and whol have to be tak
k andere opinies het ganse zorg
parlez de médeCe sont deux man
Chronic car
es aides Celles-ci
mation et
igne qui ilités qui
doit être vent faire
e MG se s choses SGM2)
liste, qui est pas
l andere voorstel
nvol zijn”
dination”
elegation o should ken into
zijn die systeem
cins qui nièresde
•
•
•
•
e
voir les chostravaille avec(SGM2)
A revision of shared care
“Cela ne sert l’autre, je crovoir s’il n’y a p
« Aujourd’hui,à chacun sepédiatre pour
We have new(payment at n
“Er is geen finmultidisciplinagedragstherapdiëtisten,….”(
Existing multiused (strength
“Anderzijds ewaar ruim opgeworden terw
The right of t
against the m
“Par rapport aMR, qui pose
ses différentes. Dc quelqu’un, n’es
f the care tasks
à rien d’envoyer is que l’on doit repas des rôles qui p
, le MG fait parfoies missions spéc
vacciner un enfanw financial modalitnetwork level?). Th
nanciering voor eair team zoapeuten of m
(SGM1) disciplinary netwohs)
een succes van p ingespeeld is, wijl er al een soor
the patient to choodel of a care del
aux mentalités en problème. C’est u
Dans un duo, lest pas au-dessu
list by profession
r 10 personnes à revoir les sacro-sapeuvent être parta
is des tâches d’incifiques. Il est dnt » (SGM2) ties that allow for his could be bette
een aantal van dials bijvoorbeeldmeer algemene
orks are a structu
lokale multidiscipwat een fenome
rt structuur beston
oice its care provlivered by a team
Belgique concernune faiblesse du s
e médecin générus de tout le mo
n can lead to a
domicile l’une deaintes listes d’actagés » (SGM2)
nfirmier. Il faut resdommage d’utilise
networks organizer used?
ie deelnemers aad voor cogne psychologen
ure that can be e
plinaire netwerkeeen is, dit is omnd.” (SGM1)
viders can be a t
nant le choix du Msystème” (SGM2)
193
raliste onde”
more
errière tes et
stituer er un
zation
an het nitieve
of
easily
en en marmd
threat
MG en
194
4.3.2. Reformchronic
Improved coopatients are newith multiple cto tailor the c“reference heshould, in cloMoreover he/caregivers, at (3) how this purpose, he/shchronic situatielderly peopleuses a shareauthorized by • Reference
care, homethe above
“Ik wil hieaangesteldook grote tgezondheid
“Les coord(SGM2)
• In our syste
roles. For from task d
“Wat betrerealiteit, weworden nuuitvoeren o
m proposal 2: A c condition(s)
ordination of heecessary to copco-morbidities. Scare to people’sealth care proviose collaboratio/she would disleast (1) needs, will be evaluatehe should be abions (e.g. cardioe).In that procesed patient file athe patient. persons are alre
e care or in geriamultidisciplinary te
er ook refereren d wordt in de geetevredenheid overdszorg valt toch o
dinations de l’aide
em tasks are relatexample, GPs m
delegation, becaus
eft de belemmerinel het is heel sim
u vandaag door aomdat ze er fina
case manager
ealth and suppope with the increaStrategies shoulds needs and inider”- a senior onwith the GP, scuss with the
preference, life-ed and eventuable to deal with aovascular and ress the referencaccessible to a
eady in action inatric care (At the eam…)
naar een ‘refeestelijke gezondher, het bestaat al e
ook onder chronisc
e à domicile, on
ted to payment symight be afraid tse of the paymen
ngen waarom hetmpel omdat de takanderen gedaan wncieel afhankelijk
for all patients w
ortive care for asing number ofd be developed idividual life-goa
r nurse for exaprovide routinpatient and i
-goals, (2) care pally improved. Fa well defined sspiratory diseas
ce health care pll health profes
n for instance pscondition it is link
rentie persoon’ eidszorg …. ik hoeen hele tijd. Geche ziektes?” (SG
les active réguliè
ystems which inhito lose work andt system
t nu nog niet zo ken die hier geforworden en dus dk van zijn. En he
Chronic care
with
chronic f people in order als. The ample – ne care. informal plan and For that scope of ses, frail provider ssionals
ychiatric ked with
die ook oor daar
eestelijke GM1)
èrement”
bits new income
is in de rmuleerd die taken et zelfde
•
•
•
e
voor de verpleblijven wassen
Early detectio
trained nurses
‘… de huisartals er inderdabij een COPDafneemt bij deen interventdagen later ndrie weken gook niet meegoedkoper kuvan nabij opvo
Some nurses
formation in c
“Ik stel me waOmdat het niein het algemeeen heel bredover de medisen werkreïnteprofielen die social verplee
“On sait que sont des infirmpersonnes on(SGM2).
Social aspect
conditions
eegkundigen, is dn is dat niet betaa
on of acute situats
ts moet niet vrezeaad een ‘casemanD patiënt om de
die patiënt, zal detie noodzakelijk iaar toe zou gaanehospitaliseerd m
er in die tijd. Opunnen werken als olgt.”(SGM1)
are not ideally eare / support man
at vragen over deet alleen om de geen.(…) Als we sde kijk moeten hesche en verpleegkegratie… Binnen
hiervoor in aanegkundigen ?” (SG
60 % des infirmièmières brevetées.nt le niveau adéqu
t should also be
dat betaalbaar, nealbaar.”(SGM1)
tions or complica
en om zijn job te nager’ aangesteld
twee dagen eene huisarts er naaris. Terwijl hij er
n wanneer het al tmoet worden en dp die manier zou
er een persoon t
ducated to coordnagement
e opleiding en degeneeskundige zospreken over zorgbben over al wat kundige zorg, maaonze opleidingen
nmerking komen.GM2)
ères travaillant à . Cela pose la quuat pour coordonn
e included in rou
KCE Report 1
een zolang ze iede
ations by highly s
verliezen, integed wordt die bijvoorn telefonische enqr toe gaan wanne
misschien anderte laat is en de pdan ziet hij die pu je dus efficiëntetussenzit die de p
inate. Need to sp
e invulling van dieorg gaat, maar deg, zou die personmogelijk is, niet a
ar ook, social, schn zijn er maar w. Sociaal assiste
domicile pour l’inuestion de savoir sner l’aide dans le
utine care for ch
192S
ereen
skilled
ndeel rbeeld quete eer er rs 14 atiënt atiënt er en atiënt
pecific
e CM. e zorg n dan alleen hool – weinig enten,
nstant si ces futur”
hronic
KCE Reports 19
“De vraag op zich neehet socialecontacten gom te defin
• One should
disease, othe service
“Le réfèrencelui qui gèrôle, il faudcas du rôle
“Case msoit biequ’on s
• This role Furthermorand encom
“De lokgezondheidpatiënten. persoon wook wat mmanagememaar zou t
• This role m
care plan m
“Dit kan ehuisarts. Dniveau zijn
92S
is inderdaad tereemt of is dat een pe? Is het eerdegaat leggen, die mniëren wat we vers
d be very clear of n patient, or on a
es available in the
nt ou le casemanère tout ce qui esdrait des aspect se du case mangermanager, n’est-ceen au courant de sache faire une int
should only tarre they should pla
mpass health prom
kale multidiscidspromotor, die Dus dat zou co
wel rechtstreeks coeer zou kunnen, ent gebruiken. Zetoch wel wat ‘coac
may overcome themanager”
evengoed ingebedDaar is ook nood an, wat meer co
echt is dat een vepersoon die diverer een type ‘coamensen bijeenbrestaan onder ‘refer
the definition of ta person (not neclocal system ?
nager? Le casemst disease managociaux, ce qui n’e
r” (SGM1) e pas un nouveaude qui existe, m
traveineuse, pren
rget some patienay their role at themotion
iplinaire netweheeft geen rechomplementair erbontact heeft met bijvoorbeeld enke
e hoeft niet per zching’ op afstand k
e difficulty of GP
d worden als praaan, maar het kanoördinerende tak
erpleegkundige dirse aspecten op voach’, iemand die
eng. Het is heel brentie persoon’”(S
this role: more foccessarily sick pers
manager, pour mgement. S’il avait est pas nécessaire
u rôle, qui supposmais qui ne néces
dre la tension…”
nts (see steppede level of individua
erken hebbenhtstreeks contact rbij kunnen zijn, de patiënten en
ele aspecten van ziekte te kunnen kunnen doen.”(SG
to play a role as
raktijkondersteunen evengoed op ee
ken tussen eerst
Chronic car
ie die rol olgt, ook e overal elangrijk
SGM1)
cused on son), on
moi, c’est un autre ement le
se qu’on ssite pas (SGM2)
d care). al patient
een met de dat die die toch disease werken,
GM1)
s “health
er bij de en hoger telijn en
•
e
tweedelijn bijklaarheid oveniveaus.”(SGM
“Le médecin gà quelqu’un eglobaux du pa
“MG coordinaduo là qu’il fau
“La coordinatc’est un autre
CM should pl
patient
“C’est peut-êLorsque le paMRS, les dplanification, déments” (SG
“La planificatisoins palliatifs
jvoorbeeld dan iser komen. Er zijnM1)
généraliste doit gaen qui il peut avoatient” (SGM2)
ateur de soins, il luut favoriser” (SGM
tion du soin et de rôle” (SGM2)
lay a key role in
être un rôle supatient a besoin ddémarches (sony compris avec
GM2)
ion des soins est s (Advanced care
s dat een andern eigenlijk ‘referen
arder le plan de trvoir confiance pou
ui faut un coordinaM2)
e l’aide, ce n’est
the anticipation
pplémentaire poud’être placé, que t) laborieuses,
c la famille, surto
nécessaire, complanning)” (SGM2
re rol, dus daar nten’ op verschil
raitement et faire ur évaluer les be
ateur de l’aide, c’e
t pas la même c
of future needs o
ur le Case Mance soit en MR ocela demande
out pour les pa
mme on le fait dan2)
195
moet llende
appel esoins
est ce
hose,
of the
nager. ou en
une atients
ns les
196
4.3.3. Reformseamle
Forms of coosoins Samenwerkinglarger than prto strengthen sprimary care. leading role in• It is very im
can at leagroup of pr
“Il ne faut pdans les tro
• Coordinatio6000 patiepractices apractices (coordinatio
“Ook belanaantal groete kunnen evolueren denk dat jeeen zekere
• From regiowithout too
“Dit kan pzorgcoördinvan huisaallemaal.”(S
• At this leveadjust loca
m proposal 3: miess care betwee
ordination at a là d
gsinitiatieveneerrimary care coorseamless care bOther networks
n that respect. mportant to look ast distinguish cooractices level) and
pas multiplier les ous…” (SGM2) on at the midleveent in general praare too small. We(around 6000 peoon possible
ngrijk binnen de eepspraktijken zijn toepassen. Dus of naar netwerke
e toch aan een mie economische reonal networks (ieo much difficulty
perfect voor enatie teams ter beartsen die daar(SGM1) el, innovative reim
ally (ie group pract
id-level scale inien hospital and hlower scale thadomicile” rstelijnsgezondhrdination structubetween hospitals between home
at the scale dimenordination at patid at regional level
niveaux, sinon ris
el can best be pactices. That wou
e should aim at biople) or networks
erstelijn, de huisavan schaalgroottof moet je naar
en, ik heb daar ginimum van 6000turn te kunnen ga CAW) referent p
en netwerk vaneschikking gestelr beroep op
mbursement systetice, network team
itiatives to improhome care are nn “Services inte
(SISD) eidszorg (SEL
ures need to be l and specialist ce and hospitals
nsion in coordinatient level, at prac(SISD, SEL, …)
sque que le patien
performed at the uld mean that acgger primary cares that would ma
artspraktijken en zte te klein om zo’grotere groepsp
geen cijfers over, 0 patiënten moet garanderen”(SGM1)persons can be
n huisartsen, er ld worden voor eedoen, CAWs;
ems might be posms etc)
Chronic care
ove needed egré de
–L) but created
care and s play a
tion. We ctice (or
nt tombe
level of ctual GP e group-ke such
zelfs een ’n model raktijken maar ik
gaan om ) supplied
kunnen en groep dit kan
ssible to
•
•
•
e
We need heaWe have tocappropriated s
“Er zijn verscen tweedelijn in de chronisonthaald gewsommigen vinten koste vanduidelijkere pgeheel en dan
‘Institutionalizhomes and ot
“… dat er in oziekenhuis.”
“Ja, er zijn nieziek zijn en ni
“Il faut de la flil y a des patihospitalières centrer sur lchroniques ql’ambulatoire,
We may alsotransversal co
“Als we blijveproberen struwerken. (…) natuurlijk heekop zetten. Inecht central gde zin van, hdoorverwijs, e
alth-plans that gocreate “care patsetting
chillende meningein ons land en o
sche zorg. De zweest. Niet iederenden dat de eersn de tweede lijn.
positie krijgen vern de positie bekijked care’ is not onther services
ons land ook ande
et alleen ziekenhuiet in ziekenhuizen
flexibilité. On a deients qui ne viennqui descendent
l’hôpital, car il equi ne vont jama
sans compter suro think about speoordination betwe
en in functie vanucturen aft e stem
Misschien moel ver en zou heel
n chronische zorggezet wordt. In eehet is mijn patienenz.” (SGM2)
o further than thethways” helpingp
en/visies over de ver de centrale porgtrajecten zijn en kan zich vind
stelijn versterkt m. Ons centrale zrtrekkende vanuit ken van de eerstelnly hospital care, b
ere institutionele z
uizen, er zijn ook n zullen verblijven
s équipes de soinnent jamais à l’hôp
vers le domicileest très clair qu
ais à l’hôpital. Il r l’hôpital” (SGM2ecial functions oren lines of care
n de eerste, twemmen op elkaar,
eten er ad hoc onze denkwijze e
g is dit echt een sen degerlijk systemt en il wil hem te
KCE Report 1
e institutionalized peopletouse the
rolverdeling eersositie van de eersniet altijd even
den in dit statememoet worden maa
orgsysteem moede zorgcircuits in
lijn of tweede lijn. but also care in re
zorgkaders zijn da
k mensen die heen.“ (SGM1)
ns palliatifs à dompital, il y a des éqe. Il ne faut pasu’il y a des ma
faut l’organisatio2) r teams that focu
eede en derde lijr, blijven we in h
teams zijn. Dit en zorgsysteem osystem waar de pm denk je niet meerugkrijgen als ik
192S
care. most
stelijn stelijn goed
ent en ar niet t een n zijn
esting
an het
l lang
micile : quipes s tout alades on de
us on
ijn en hokjes
gaat op zijn atient eer in
k hem
KCE Reports 19
“A quelle éActuellemeSISD sont doit être int
• Belgian “readaptation
“Het is ookelkaar moezich, er zijgebonden
• We do nootherwise w
“J’ai des dfaut partir dde la concce qui estravaillent à
“Il ne faut fonctions achacun, del’on sache
• Using “impfor resourc
“Een heel pter ondersteen aantalveel lager. voegen… is die toelfinanciering
• The existinis now at a
92S
échelle se trouve lent, les RML sont centrés ‘servicestégrée” (SGM2) eform” must alw(to local context)
k belangrijk dat deten kunnen besjn veel vertaalslagzijn.”(SGM1) t have to createwhat already exist
doutes par rapporde l’existant.Les Scertation. Dans la st absolument ià l’hôpital, en plus
pas créer de noavec des profils be manière à ce qà qui l’adresser…
pulseo” at a largerces to organize su
praktisch aspect vteuning van huisal GMDs, maar daMaar het is wel
We hebben een flaat om op netwegsmodel.”(SGM1)ng palliative team a too large scale (a
le Case Manager centrés ‘médecin’. Il faut les intégr
ways look at theand general polic
die verschillendestaan. Dit is ook gen op zich mog
new structures t
rt à la création d’SISD ne font pas d
pratique, c’est minsignifiant. (…) s du domicile…”(S
ouvelles structurebien définis et redque, quand le pat…” (SGM2)
r scale as it is nowch a coördination
van deze gedachartsen ‘Impulseo’, an kom je niet opal een model dat
financieel systeemerken te werken.) / network may alsaround 250 000 p
? Par qui sont-ils n généraliste’, et lerer, car la prise en
e balance betweecies
modellen op zichet aspect ‘loca
gelijk maar die da
of coordination,
’une nouvelle strude la coordination
mille concertationsBeaucoup d’inf
SGM2)
s, oui pour de ndéfinir les rôles detient sort de l’hôp
w may help in … ?)
te, we hebben eedat werkt met critp die schaalgroept bestaat om dingm nu dat ook wel . Er bestaat ee
so be an entry-popeople)
Chronic car
payés ? es SEL / n charge
en local
ch naast aliteit’ op an lokaal
but use
ucture. Il n, ils font s par an, firmières
ouvelles e tout un pital, que
(looking
en model teria van p, het is gen in te opgevat n nieuw
oint but it
4
TcccfInain•
e
4.3.4. Reform pneeds of
The support of pchallenge for thecare in institutcare/supportive nfor persons witncreasing the oaccommodationsnstitutionalizatio There is a nee
for informatiohospitalisation
“En anderzijdsergens naar tussen uit mantelzorgers
“Souvent, il y n’ont rien à fa
“Qui doit orgaon peut les sêtre pas aux S
“Il existe des pmais c’est tropa une certain(SGM2)
“Dans mon exau niveau du fréquent. On fproche. C’estpourrait être pcentres de rép
proposal 4: the rpeople with chro
people with limitee following decadtions should bneeds. On the otth limited care/offer of care/sups for relieve ons. ed for more ‘resp
on about the exisns…
s een aantal ‘resptoe kan gaan, o
kan, dat es.”(SGM1)
y a hospitalisation aire à l’hôpital” (SG
aniser ces structusoutenir pour qu’eSISD de devoir or
possibilités pour sp peu exploité. C
ne méconnaissan
xpérience, la premsoutien de l’aide finit par hospitalist toute cette orgprésent et permetpit, les centres de
right environmeronic health probed or high need des in Belgium.
be reserved forther hand specifi/social needs, pport at home are possible
ite’ care organisasting formula, in
pite’ formules, ofwofwel dat de maer thuis oplo
par épuisement GM2)
res de répit ? Leselles en organisenrganiser un truc m
soulager l’aidant pCe serait un plus pnce, ou bien c’es
mière chose qui poinformelle, motif der pour pallier à l’anisation de souttre aux gens de re jour, il manque d
ent according to blem
for chronic careOn the one han
r people with ic support is reqoutside institutas well as adasolutions to a
tion, as well as a order to avoid
wel dat de patiënt antelzorger es erossingen zijn
du réseau, alors
s ligues en organnt plus. Ce n’est
médicalisé”(SGM2)
proche en court sépour tout le mondest difficile à organ
ose problème, sed’hospitalisation le’épuisement de l’autien de la famillrester à la maisonde places…” (SGM
197
the
e is a d the high
quired tions. apted avoid
need some
eens rgens
voor
qu’ils
nisent, peut-)
éjour, e. Il y niser”
e situe e plus aidant le qui n. Les M2)
198
• …And a ninformation
“Et aussi lpour que jude sa solitu
“Un autre pville pour adéveloppée
“Les centrechose de mPremièrem€/mois, ceDeuxièmemdétournemqu’ils sont en RW. C’e
• Social secinformal ca
“Eén van dhet ontbreworden, mmoeten zijn
• The divisioand social
need for day cenn about the existin
le soutien d’activiustement la persoude parce que ça
problème est l’isoaller vivre dans une….”(SGM1)
es de jour existenméconnu. Il y a tr
ment, le coût : si oe qui veut dire ment, ces centr
ment de clientèle pcomplémentaires
est une faiblesse urity and financia
aregivers and form
de zwaktes zijn deeken van een stamaar wel dat er bn ivm hun sociaal
on in our national acare need to be
tres in rural areang day centre…
ités intergénératioonne âgée qui pefait partie de la q
olement de la pern village, où l’infra
nt, (mais) il s’agit rois éléments quion y va régulièrem
que ce n’est res de jour sopar les services ds. Troisièmementdu système…” (S
al incentives to almal recognition for
e lacunes van deatuut, ik zeg nietbijvoorbeeld een
statuut bijvoorbeand regional systee dealt with at th
a, as well as a n
onnelles au niveaeut rester chez elualité de vie.”(SG
rsonne âgée, qui astructure n’est p
effectivement de i jouent en leur dment, c’est de 30pas accessible ont perçus comde soins à domicit, il n’y a que 200SGM2)
leviate the burder informal caregive
mantelzorg, bijvot dat ze moeten bepaald aantal geld.”(SGM1) em between medhe work floor. Th
Chronic care
need for
au local, lle, sorte
GM1)
quitte la as aussi
quelque défaveur. 00 à 400
à tous. mme un ile, alors 0 places
en of the ers
oorbeeld betaald
garanties
ical care e actual
•
e
state reforms role in that as
“Hier moet erstaatshervormzorg versusvergemakkelijsignaal, we zbij elkaar bren
“Inderdaad endeze structuredeze meer opdit. Het moet formules vindte doen same
Chronic patieproducers in o
“Met ‘environvormen, niet aom de mensewerk te houdom te werken
have overlookedpect
r vooral rekeningming is dat een g
welzijnszorg. Mjkt. Dat is beleidsullen toch moetenngen.”(SGM1)
n daarom moet eren structureert oop elkaar gaat afstewel op de werkvl
den die de welzijnenwerken. “(SGM1ents should be sour society
nment’ gaan we alleen materieel m
en terug aan het wden, dat is zeker
.”(SGM1)
d that issue. Mun
g mee gehouden grote zwakte: de Met de staatshesmatig gezien tocn zoeken naar sy
er gewerkt wordenok al zijn er andeemt. Met verbeeldloer georganiseer
ns- en de niet wel1) stimulated to be
ver: het is eenmaar ook werk bijwerk te krijgen maniet onbelangrijk.
KCE Report 1
icipalities could p
worden: ook na split tussen medrvorming is datch een heel belaystemen die deze
n aan een formulere bevoegdhededing en creativiterd worden. We molzijnssector met e
e and remain a
n integratie in diijvoorbeeld. Niet aaar ook om ze aaOf om ze toe te
192S
play a
onze dische t niet angrijk
twee
le die en, en it kan oeten elkaar
active
iverse alleen an het
laten
KCE Reports 19
Theme 2
(Re) defining t
Strength
Professionals “De verpleegkundigzicht over het mediop zich neemt. Wij mensen helpen en evengoed. De huisabeslist ook de patiëlaagdrempelig is. Tbijsturen.(B1VL)” «La place à donnerdonner à chacun ua parfois aussi envplein droit, ce qui eun tel nœud à défa
The strength obetween profe“Dans une MM, c’ed’échanges inter-m
92S
he roles of healt
are willing to takge (in groepspraktijk) sche luik, maar het homerken zelf wel dat wondersteunen die dat arts beslist dan dat hij
ënt dat de verpleegkunTenzij de huisarts zegt
r à l’aidant est très comne place qui lui convivie de coordonner. E
est logique aussi, parcire, ce qui décourage
of interdisciplinaessions and tasks
st plus facile d’organismétiers, sauf quand on
th professionals
ke the role as cokrijgt eigenlijk een cen
oeft niet altijd de huisawe onszelf ook goed m willen op zich nemenj een deel van zijn coöndige die rol op zich ka: nee, het is te comp
mpliquée dans une reent et la fameuse que
Et pourtant, les profesce que ça fait partie dparfois les familles à f
ary team in orgas ser les choses. Dans lse voit en coordinatio
and their trainin
ordinator ntrale rol, de huisarts
arts te zijn die de coörmoeten bijscholen en j. Een verpleegkundige
ördinerende rol delegean nemen doordat hij/lex, dan moet je dat
lation MG-patient. Notestion de ‘qui coordonssionnels s’attribuent de leur formation. Maisfaire appel à ces servi
anizing the comm
les autres cas, il y a peon. On ne s’écrit pas.”
Chronic car
ng
Wea
behoudt wel rdinerende rol e moet e kan dit
eert. Soms /zij
tamment pour nne?’. L’aidant
ce rôle-là de s c’est parfois ices aussi. »
munication
eu
Lac“La dmétieclois Lacin p“De daarvmedizijn. er isbesta
GPsstim“Rigiook geenprobhuisavlot snu eeniet z
GP “De alles
« Podevie
e
akness
ck of inter-profesdifficulté aussi, c’est quers. On a le dossier inonné par métier. »
ck on agreementprimary care and
zorg rond de patiënt rvoor opgeleid wordt. ische, maar ook over Die rol wordt nu niet o
s weinig opleiding, onaat wel maar het word
s have not enomulated
diteit van planning enniet op de hoogte va
n kennis van de verscleem maar anderszijdartsen willen dit wel osysteem zijn, haalbaaren financiële vergoedizo belangrijk. De zorg
has too many tahuisarts wil de centra
s, ze hebben ondersteu
our ce qui est de la réent moins accessible,
ssionals communu’on a des tas de moy
nfirmier, le dossier méd
t about who have beyond the medzou toch gecoördine
Hij moet een overzicde psychosociale pro
opgenomen, de groepnvoldoende vaardighedt niet opgenomen.”(B
ough support.
n wie de planning moen wie die planning zochillende systemen dids ook een kennis tekoop zich nemen maar er en goed uitvoerbaaring voor huisartsen vo moet vooruitgaan, en
asks + there is a ale zorg behouden euning nodig.”(B2VL)
éponse aigüe aux situ, mais on lui donne to
nication tools yens de communicatiodical”” Pour les guidel
e to play the roledical needs eerd worden door eenht hebben over het goblematieken,… de hup die de rol zou moeteeden, geen kennis, tij2VL)
Group practic
et opmaken is ook eeou kunnen opmaken oe mogelijk zijn. Het isort over de verschillener moet een omkader. Financiële incentiveoorzien die een zorgpln de zorg gaat beter.”(
lack of clear taskn een aanspreekpun
uations, on voit que loujours le rôle centra
on, mais toujours intra-ines aussi, c’est vraim
e of care coordi
n coördinerend persogeheel en niet puur ovuisarts kan niet de spen opnemen doet dit nd, geen voorzieninge
ces should also
en probleem. Huisartsop hun initiatief, ze hs dus enerzijds een a
nde mogelijkheden. Joring komen, en er mo
es zijn niet zo belangrijanning opmaken, maa
(B2VL)
k delegation t zijn, maar ze kunne
le médecin est surchal et il n’est pas très b
199
-ment
nator
oon die ver het
pilfiguur nu niet, en. Het
o be
sen zijn hebben attitude ongere
oet een jk, er is ar dit is
en niet
argé, il bien au
200
Chronic care
centr
“‘mangeladhogeop zibiedevan manamulti
Pha“De rde betro
“Peumaistendasont
Man“In dgeneweinwat
“Il y ades cpas s
Leg“Wet(eerstaakdverplHet
e
re de l’information qua
nager’ – (GP managden woord. Alle hulpvere niveau en ook het ich nemen, iemand men heeft, hoe het aanbprotocollen, procedureagement, zal de hanidisciplinaire netwerke
armacists are norol van de apotheker kaart gezet worden
okken”(B2VL)
u de pharmaciens d’ofs ce n’est pas du toance à se sentir hiérapas du tout ouverts à
npowerplanning e opleiding zit weinig
eeskunde, maar eensig endocrinologen bvber effectief nodig is.” (
a beaucoup d’AS dispcentres d’action globasuffisamment.” (B1FR
gal framework anttelijk blijft de artsstelijnsverpleegkundigdelegatie: zij blijven wleegkundigen maar blgekke is dat we patië
and il y a une situation
er = afstemmen vanverleners moeten op lagere niveau: ook de
met een brede basis opbod kan terecht komees- en werken binnenden hiermee vol heb
en die taak aan kunnen
t enough involvein de chronische zorg
n. De apotheker is
fficine ont une collaboout la majorité, pourqarchiquement inférieurecevoir des informat
is not ad hoc sturing naar wat we e
s je het bent kan je jb. Ik denk ook aan de(B1VL)
ponibles. Il y en a danale, les services d’aideR)
nd legislation mas verantwoordelijk, ge): het speelt ook wel wettelijk verantwoijven zelf verantwoordënten leren om taken
n complexe. »
de zorg binnen eenelkaar afgestemd wo
e patiënt moet er bij bepleiding, kennis hebben bij de juiste persoon
n de eerstelijns praktijbben, ‘zorgmanager’. n.(B1VL)
ed in chronic carg is nog niet sterk gens zeer laagdrempeli
ration fructueuse avecquoi, parce que les prs aux médecins géntions ou des conseils d
effectief nodig hebbenje specialisatie kiezen eerstelijn. Daar is er
s les MM, des CPAS,e aux familles. Il y a plé
ake task delegatiook al werk je een rol in hoever
oordelijk. Ze willen wedelijk.
zelf te doen (insuline
KCE Report 1
n huisartsensetting.)- orden, het managen vetrokken worden. Wie en over wat de eersten, afspraken maken opjk De specifieke taak:Ik denk niet dat de
re noeg. De apotheker mig maar ze worde
c les médecins générapharmaciens d’officin
néralistes, et que les Mde la part de pharmac
n - vb numeros clausun, vb teveel cardiologook te weinig gestuur
des coordinations deéthore, mais on ne les
on difficult met protocollen e
rre artsen willen gael en vertrouwen ook
e spuiten, optrekken, .
192S
is een van het kan dit
e lijn te p basis alleen Lokale
moet op n niet
alistes, e sont MG ne
ciens. »
s in de gen, te rd naar
e soins, s utilise
en zo. aan in
op de
.. ) wat
KCE Reports 19
Threats
92S
Chronic car
verpl
“Oui,prép
A la“Strecoachoofd
Not“Er isaanwmogecomp
Opp Crespe“genveel iema
e
leegkundigen dan wee
, les aides-familiales narer les semainiers.
ack of coaching tess onder hulpverlenechen. Werkstress is hedverpleegkundige. - E
t enough interdiss echt nood aan een wezig bij enkele opleielijkheden, en beperkpetenties moeten uitge
portunities
eation of new proecialised primaryerieke educator:psychchronische aandoenin
and die wat meer disci
er niet mogen doen! “(
ne peuvent pas pour d
to overcome strers is een probleem - Hetzelfde, hangt van je
Er is nood aan coachin
sciplinary educatinterdisciplinaire opleidingen. Zo kan je deingen. Tools voor leveebouwd worden zoals
ofessions (genery care nurses, geholoog, kunnen educengen, ook wat verpleeplines of competentie
(B2VL)
des raisons médico-lé
ess of professionHet heeft ook te make mensen op de bepaa
ng van hulpverleners.”
tion iding, dit ontbreekt ece verschillende discipenslang leren zijn zeks planning,…”(B2VL)
ric primary healteneric educatorseren, noties diethiek wegkundige activiteiten s in zich heeft”(B2VL)
égales. Elles ne peuve
nals en met hoe je een groalde diensten af, bv a(B2VL)
cht op dit moment, of lines leren kennen m
ker noodzakelijk en be
h care professio,...)
want is een probleem bkunnen uitvoeren- noo
)
201
ent pas
ep kan andere
is juist met hun
paalde
onals,
bij heel od aan
202
4.3.5. Reformlevel
At primary carecognized (leIn particular nreceive new fu(e.g. washing)education leveThe GP has bemedical care bthis complex needed within(see point 2) acascade of deright place” caskilled primarythe implement• Profession
role of the
“Je voegverpleegkugaan verscwerken: daovergenomaanbiedt. H
“Er gaan zede verdedizorgtrajectespuiten, da
“Het invoebedreigendcomplemen
m proposal 5: cre
are level, new funegally and in the nurses with a higunctions (e.g. cag) should be deel. een and is still a but he/she has inand time-consu the primary car
and community pelegation of actiall for reformed ly care nurses, ctation of these neal organisationstepractice assistant
gt nieuwe hogundigen of paramechuiven. Waarschat het werk dat vamen wordt door Het moet strategis
eker territoriumgeiging van het beren, dat de dietiste
an vrees ik het erg
eren van nieuwed over voor de ntair wordt bescho
eation of new fu
nctions need to borganisation of t
igher education ase managementelegated to nur
key actor in the ncreasing difficuuming task. A bre team, i.e. betwpharmacists. Onivities. “The riglegislation, specclinical pharmacew roles. end to protect thet (In Flanders) is s
ger gespecialiseedici, en dat maa
hijnlijk zal het in dndaag gedaan woanderen en dat
sch lopen.”(SGM1
evechten zijn maaroep zien. Zoals e die educatrice isgste.”(SGM1)
e beroepen in bestaande beroeouwd.”(SGM1)
unctions at prima
be created and othe health care slevel (e.g. MSc)
t). In parallel, basrse aids with a
coordination of ulties to cope alobetter share of tween GP, case mne solution is to sght care providecific training (e.gcists) and incent
eir role. For instastill an open discu
eerde niet-artsekt dan tijd vrij, da
de andere richtingordt tegen een hot je tegelijk iets
1)
ar anderzijds gaanwe hebben gezies, niet mag leren
ons systeem kepen omdat het
Chronic care
ary care
officially system).
should sic care a lower
chronic one with tasks is manager set up a
er at the g. highly tives for
ance the ssion
en toe, an kan je g moeten oge prijs,
anders
n we ook en bij de om in te
komt als niet als
•
•
•
•
e
New roles retheir working
“Heel veel oobetrekking totzoveel zakenmanagers zijnvoor een deelkrijgen in hun
New roles req
“…Et le plannimportant aus
Need to (newteam
“Est-ce que cinfirmière soigterrain, et qu’aformation spéc’est mieux. Çdes tâches de
New roles canand nurse ascurrent AR 78
“Een opportunvan de zorgveopen ligt, mozorgkundigenminister. Dus onderuit door je daar ruimverpleegkund
“On doit faire l’on revoie la
quire new curricuparadigm
orzaken daarvan zt nieuwe functies dn fout lopen. An, of niet zo goed l aan het feit dat zopleiding.”(SGM1
quire optimal work
ning, la programmssi”(SGM1) w) specific training
c’est quelque chosgnante ? S’il y a au sein de ces éq
écifique par rappoÇa veut dire que ce soins à propremn go beyond the rssistants, but also8
niteit op dit momeerpleegkundigen oet gevoerd wor in de thuisverpleer is op dit mom
r het creeren van mte vrij te kunnendigen”(SGM1)
évoluer le rôle deliste d’actes… Il y
ula, to begin with
zitten in de opleiddie je zou wensen
Als artsen vandakunnen multidisci
ze daar te weinig 1) kforce planning
mation des ressou
g for primary care
se de diffèrent, codes équipes qui s
quipes il y a un infort à la gestion decette infirmière va
ment parler” (SGM2role of nurses, foro other professio
ent is dat het debain de thuiszorg, orden. Er is een eging, die is opgment een enormezorgkundigen in d
n maken voor an
e l’infirmière, ce qy a tous ceux qui
KCE Report 1
h GP, in order to
ding en niet alleenn, maar ook waaroaag niet zo’n giplinair werken, ligof geen aandacht
urces humaines q
nurses working i
oordinateur de sosont organisées sfirmier, moyennane la maladie chron
aussi continuer à2) r instance pharmaon not included i
at over het inschaop dit moment vo
studie geweest geleverd, die ligt be opportuniteit omde thuisverpleging
ndere opdrachten
qui n’empêche pasne sont pas dans
192S
o shift
n met om er goede gt ook t voor
ui est
n MD
ins et sur le nt une nique, à faire
acists n the
akelen olledig
over bij de
m van g kan voor
s que s l’AR
KCE Reports 19
78: les éprofessions
• Which newcare system
“Le rôle podétailler” (S
“Dans d’auattitré. En Bentre le phgénéraliste
“A la base,soignant. Mde ce qu’il habitude dterrain” (SG
• Because o• Some prac
not new ro
“Een van professionatoekomst gniewe funtendens va
4.3.6. ReformSpecialized hprofessions) sThey should home to ensurA discharge sthrough arranshould coach technical issue
92S
éducateurs, les s… Il faut faire plu
w role for the comm ?
ossible du pharmaSGM2)
utres pays, dont Belgique, c’est plu
harmacien hospitae” (SGM2)
, il y a un problèmMême si le pharmdélivre, il est parfe mise en commuGM2) f cascade is a risk
ctices can be deleles
de bedreigingealiseren van wat gaat di tons onn
nctions, niewe opan onze maatscha
m proposal 6: Spospital functionshould focus onalso invest in pre the transition
specialized nursngements with and support the
es.
psychologues, us simple” (SGM2
mmunity / clinical p
acien d’officine, c
la Hollande, le pus difficile, il y a ra
alier, le pharmacie
me de communicamacien a un rôle efois mal accueilli pun des compétenc
k for deteriorationegated to the care
en van ons syst de mantelzorg zoemelijk veel gepdrachten profes
appij” (SGM2)
pecialized hospitns (clinical MD n specific problepatient autonom
n with self-manage should ensurethe primary ca
e primary care le
mais aussi les2) pharmacist in the
ce serait nécessai
patient a un phararement une cooren d’officine et le m
ation entre pharmet qu’il a la respopar le médecin. Ilces qui n’existe pa
or loss of Qualityegiver, andrequire
stem, is dat wezou kunnen doenld kosten, als wissionaliseren. Di
tal functions specialists and
ems in acute comy before the regement in primae a seamless traare team. Finallevel for specializ
Chronic car
s autres
e chronic
ire de le
armacien rdination médecin
macien et onsabilité l y a une as sur le
y e may be
e verder n. In de ij blijven it is de
d allied ontexts. eturn at ary care. ansition ly, they zed and
Sadmnc•
•
•
e
Some suggestionare the appointmdischarge procesmanagement of tnurse/allied profeclinical specialist Telemonitorin
earlier from ho
“Een studie inaantal hospittelemonitoringpatiënt kan sntelemonitoringmeldt aan de problemen ka
“Die dimensieeerste en dwordt.”(SGM1
At present thprimary care a
In hospitals wkidneydiseasefunctions
“Er wordt al gin sommige daan huis, demodellen.”(SG
‘Die rol moet aspect zorg voorbereidingvoorwaarden Alle voorwaaenzovoort. “ (S
ns from the anament of a contact
ss, (e.g. to contthe patient aboutfessional, and cats and primary cg can help to obospitals, but evide
n Denemarken totalisaties voor Cg van de patiënneller het hospitaag door nurse die huisarts, de huisa
an vermijden.”(SG
e zou er zeker mode tweede lijn, 1) ere are 5 experiand the hospital s
we have extern liae) , and within
geïnvesteerd in eediensten in outreaenk aan dialyseGM1)
beter gedefinieerdat moet overg
g van het ontslagvervuld zijn om u
arden: dat kunneSGM1)
alysis of other cperson in the ho
tact the primary t his/her conditioare plan orientedcare providers. bserve patients thence of efficacy is
oont dat men er iCOPD manifest nten als ze het al verlaten, hij woreen probleem snarts start een cortM1)
oeten inzitten, het door wie het
ments for better sector aison nurses (for
shortly there wi
en ontslagmanageaching nurses, di. En ‘liaison-nur
rd worden. Er zijnedragen worden,
g, nl. nakijken meuit het ziekenhuis en huisproblemen
chronic care sysospital to supporcare team), the
on(s) by a speciad exchanges bet
hat can be dischas lacking at presen
in geslaagd is omte verminderen hospitaal verlate
rdt opgevolgd voonel kan detecterenticoide op, waardo
t is een brug tusset ook georganis
coordination bet
instance for end ill be a list of
er in het ziekenhuie de zorg gaan rses’ Er bestaan
n 2 aspecten: er i, maar er is ooet de eerste lijn te kunnen vertre
n zijn, zoals trap
203
stems rt the self-
alized ween
arged nt
m het door
en.De or een n, dat oor hij
en de seerd
tween
stage these
uis, en doen
n wel
is het ok de of de
ekken. ppen,
204
• Need to ceducation…
“C’est surtoautonome
• In protocol • Think abou• Maybe the
is more ap
“Maar waabedreigendzorgtrajectetweede lijneducator zogenblik vowerkt dat n
clarify the conce…
out là qu’il faut inque possible”(SG3 projects we hav
ut the KCE seamlewording of coach
propriate
ar ik me zorgen od wordt ervaren en ziet, daar zit
n naar de eerste lziekenhuis naar oor ons ‘een blanniet? We betalen d
pt of empowerm
nvestir pour que lGM1)
ve many exampleess care study hing is wrong in th
over maak is dat vanuit eerste li
een expliciet modlijn in, van de speeducator eerste co’, we weten dadat maar…?“(SGM
ment, as it is mo
le patient devienn
es of coordination
his respect and su
dit heel dikwijls ijn. Zoals je ookdel van coachingecialist naar huisalijn, en dat is v
ar niks over. WerM1)
Chronic care
ore than
ne aussi
upporting
als zeer k in de
g van de arts, van voor het rkt dat of
e
KCE Report 1192S
KCE Reports 19
Theme 3 EmpowermentStrength Patient educat“Ons zorgprogrammverpleegkundige zieeducatie .”(B1VL) “Ici dans notre strcontact avec des dmieux la diététiquetrucs, on les lui a ala maladie en ellepourrait… » (interviPatient organis“Er wordt geregeld lijnen, expertisecenartsen proberen ee(ziekenhuisspeciali“Si on veut que le choix sont difficilesl’occasion de rencgroupe d’entraide, important pour comdonner l’accès aupersonne, sans rienSupport for inf“Communicatie memantelzorger zo hogeorganiseerd, dit idelen. Aanbieden v“Pour ce point de von a besoin d’un proches de personnde psychologue ranécessité. » (B1FRWorking with vcaregivers “Inzetten van vrijwilinschattingsvermogworden om nabij tete hebben naar de
Threat
92S
t and support of
tion by specialisema is zo georganiseeret, ze gaat het gezon
ucture, on n’a pas ddiététiciennes, et je me de l’insuffisance carppris à Paris. Il y a co
e-même, on voit tout iew) sations are an adcontact opgenomen m
ntra, referentiepersoneen zekere samenwerkist) Ik geloof daar sterkpatient puisse décide
s lorsqu’ils viennent decontrer des pairs. Il e
car ce n’est pas propmbattre l’isolement ex aides financières, n attendre en contrepaformal caregivert en informeren van de
oog mogelijk houden eis niet ziekte specifiekvan ‘adempauzes’ voovue-là, l’aidant n’est pasoutien. Moi-même j’nes souffrant d’insuffisattachée à l’équipe
R) volunteers to su
lligers naast mantelzogen, overschat de mane zijn maar geen vriendhulpverlening toe.”(B2
patient and info
ed nurses rd dat elke patiënt diedheidsgedrag bevrag
de diététicienne, maisme rends compte querdiaque que la diététicomme ça quelques crit
de suite si le patien
dded value next met patiëntenorganisaen,dit zijn allemaal aanng te krijgen met dezek in, aanvullend.”(B1Ver pour lui-même, il fes professionnels qui est important de donposé systématiquemeet pratiquer le self-he
… mais aussi aux artie » (B1FR). rs e mantelzorg is heel b
en hen mogelijkheden k. Lotgenoten momenor deze mantelzorgersas entouré. On a beso’ai pris l’initiative d’orsance rénale, avec uninterdisciplinaire adul
pport and streng
orgers, trainen van hulpntelzorger niet (vermoden te worden, empat2VL)
rmal caregiver
op raadpleging komtgen met daaraan geko
s on met toujours noe mon infirmière conncienne… elle a de notères, mais la gestion nt gère sa maladie o
to the educatorties , o.a.-platform, -lig
nvullende opties , ook e organisaties. VL) faut qu’il comprenne lsont experts. On devner l’information par
ent par les professionnelp. Il ne s’agit pas srelations, qui peuven
belangrijk. De draagkrbieden. Er worden inften om ervaringen te k.”(B2VL)
oin de plus qu’un supprganiser une associatn psychologue. Parce lte, alors que c’est
gthen the informa
pverleners in een goeeidheid,…). Ze moeteisch te zijn, en een sig
Chronic car
Wea
eerst de oppeld ook
os patients en naît beaucoup ombreux petits
psychique de ou pas, et on
ga, 0800 sommige
es choix. Les rait lui donner rapport à un
nels. Ceci est seulement de nt soutenir la
racht van de fo momenten kunnen
port technique, tion avec des qu’il n’y a pas vraiment une
al
d en getraind gnaalfunctie
Fina“(ThuonafhhoudTheedugen“Er isgerevoor Lim"Pousystèn’estdanss’en indisInfo“Tocbeseinform“ LorlorsqLegund“Menrol vaWe mmant
Opp
e
akness ancial barrier foruiszorg): Ja,het is allehankelijk te maken, in
den.”(B2VL) ere is a lack of a ucation, but with neric education s nood aan een eerstedeneerd wordt bij de zverschillende zaken t
mited access to inur pouvoir faire des choème, outre une informt pas réellement au ces une forteresse dont icharger ? Le MG (a-t-
spensable ?). Pour qu’ormal caregiver ih bereiken we onvoldo
effen niet altijd dat ze mmatie mislopen. “(B2Vrs des réunions avec dqu’on fait la dialyse à dgal framework foderstand nsen zijn niet vertrouwan de mantelzorger kamoeten ook opletten otelzorgers in regels te
portunities
r patient empoween in de diabetes sett alle andere settings w
generic patient ethe rising co-mo
elijns: generische educzorgtrajecten, terwijl vtegelijk moeten geholpnformation to alloix, le patient doit êtreation sur la maladie. L
entre du système (impl ne peut pas sortir et -il assez de temps pouil y ait autonomie, il fas isolated oende alle mantelzorgmantelzorgers zijn, enVL) des aidants, on s’est redomicile (B1FR). r patient rights a
wd met de rechten vanan zijn. Er is weinig opomde mantelzorger nie
laten lopen.” (B2VL)
erment ing waar je betaald woword je betaald omde
educator, there isorbidity there is a
cator. Het probleem neel van deze mensen
pen worden.”(B1VL) ow for patient em
e informé quant aux poLe patient ne peut pasortance de l’empowertoutes ces volontés s
ur l’exprimer et faire ceaut qu’il y ait un choix p
gers, want dit blijft tochn dus op deze manier h
endu compte à quel p
and protection is
de patiënt en de manpenheid. Het is een zeet te sterk gaan regulie
ordt om de patiënt patiënt afhankelijk te
s a lot of fragmea need for more
u is dat te vaak in vakmulti-morbiditeit hebb
mpowerment ossibilités qu’offre le s prendre des décisionrment). Il se trouve comont un peu vaines. Quette information possible."
h nog iets van thuis, mheel veel ondersteunin
oint on est isolé chez
s difficult to
ntelzorger en wat de jueer moeilijk wettelijk kaeren, het is een valkui
205
ented
kjes ben en
ns s’il mme ui peut
mensen ng en
soi
uiste ader. il om
206
4.3.7. Reformassociinforma
One cornerstorole. Supportdelivered at municipality, scause psychohospital admisshould be offe(financial) accare day care c• Information
clubs, mutpatients an
“Le rôle deaidants, des’adresser”
“Quand onmoment, d’encadrem
• Informal cimportant p
m proposal 7: neiations and to offal caregivers. one of any healt and coaching the local (i.e.
sickness fund) lological or healtssions/institutioered (in terms ocessibility) at theentres, respite anal care and supptualities and alson informal caregive
es mutuelles deve manière à ce qu” (SGM1)
n a réussi à mettrl’aidant proche
ment” (SGM2) aregivers complapartner (threat)
eed to clarify theffer respite care p
lth system is thof patients andpractice) and
levels. A lack of th problems, asnalization for thf adequate infore local and regi
at home. port can be given o municipalities. ers (opportunity)
vrait être de fourue ces derniers aie
re toute une struce fait marche
ain that they are
e role of patient possibilities for
he informal cared care givers sh
regional (i.e. hf caregiver supps well as inapphe patient. Resprmation, availabiional level. Illus
at different levelsThis should targ
rnir des informatient un point de co
cture en place, auarrière, par
e not often seen
Chronic care
egivers` ould be
hospital, ort may ropriate
pite care ility and
strations
s: patient get both
ions aux ontact où
u dernier manque
n as an
•
•
e
“Mantelzorgersérieux wordvoldoende uit
“Au même titl’échange d’eproches peuvbesoins de ce(SGM1)
There are acommunity) fopolitical climat
The role of pacare, it is firsexperiences
“Il y a égalempilote à ce niv
“De rol van demeer beklemtin ieder gevalpatiëntenorgaplaatje.”(SGM
rs klagen er dikden genomen e
aan de mantelzo
tre que les assocexpérience entrevent être une aiette population, n
already financial or informal caregivte is a threat to thatient association stly about helping
ment des groupes veau-là” (SGM1)
e patiëntenorganistoond worden, is l veel ruimer dan anisatie veel M1)
kwijls over dat zn de hulpverlen
orgers.”(SGM1)
ciations de patiene patients, les ide précieuse po
notamment pour c
incentives (in tvers and patientsis (threat) is much more th
g each other, fac
de parole qui exis
saties en mantelzveel meer en op‘respite care’. Wemeer opnemen
KCE Report 1
ze niet voldoendners leggen het
nts sont une aide assocations d’aiour l’identificationce qui touche au
the Flemish regs. However, the cu
an the issue of recilitating the shari
stent, il y a des p
zorgers op zich mo veel meer nivea
e moeten de rol van in het g
192S
de au t niet
pour idants n des répit”
ion / urrent
espite ng of
rojets
oeten us, is an de ehele
KCE Reports 19
Theme 4
Payment syste
Strength
Capitation sys“Forfaitaire systemetoepassen”(B1VL)
Episode and o“Dans les trajets dedépasser le paieme
‘’Un épisode de maproblème, ça peut ê
92S
ems and influenc
stem en geven veel meer fle
or health probleme soins, on voit une tenent à l’acte. Un finance
aladie, dans notre jargêtre un problème chro
ce on care
exibiliteit,forfait voor e
m – based paymendance à vouloir finanement au problème.’’
on de GP, ça a un débonique. C’est plutôt un
educatie, zo kun je dat
ent system ncer des épisodes, à v
but et une fin. Un finan mieux.’’
Chronic car
Wea
t flexibeler
vouloir
ncement au
Intecollcare‘’Poupas pparfoIl n’e
Diffpro"Pasdeuxl’actemédifactu
Fee ‘’Le ce soconsalorsellesmoitipaiem
Pay’’Aveà l’acoù ley a dsoignenvosystègénédont
e
akness
eraction betweenlaboration – diffie ur l’instant, il n’y a pas partie d’une équipe mois, c’est une rétrocessexiste pas d’équipe mo
ferent type of payviders in the sam
sser au forfait? Dans nx ne marche. Dans note et on a tout le tempsicale, mais ils aiment b
ure, on se rend compte
e for services is aproblème du paiemen
oit rentable sur une msciencieuses vont passs du coût de la conscies n’ont même pas le chié déshabillée devant ment à l’acte incite les
yment system disec un DMG par an, je ncte est axée sur les mes deux systèmes cohdeux MM au forfait, nonés à côté, mais ils aimoie la facture, on se reème nous forme à soigérale qu’on se rend co
on doit tenir compte,
n financial incentculties for some
de financement prévuultidisciplinaire hospitasion du montant, par lobile qui pourrait organ
yment system imme area leading tnotre système, où les dtre quartier, il y a deux
s des problèmes, parcbien notre kiné. Quane que le patient était a
a push for quantnt à l’acte c’est qu’elleatinée. Les indépendaser beaucoup de tempence professionnelle dhoix, elles doivent alleson lavabo pour que l
s gens à produire beau
sease oriented rane vois pas dans le finaladies, pas sur les paabitent, je pense qu’a
ous on est à l’acte et oment bien notre kiné. nd compte que le patigner des maladies, pa
ompte qu’il y a un peu mais ce n’est pas dan
tives and interdise professionals (i
u pour l’infirmière à doalière (pas dans la no’équipe hospitalière, àniser ce genre de cho
mplemented by dto administrativedeux systèmes cohabx maisons médicales ae qu’ils sont soignés dd on a facturé et que l
au forfait dans l'autre m
tity and may leads (infirmières) doiventants choisissent alors ps, mais ce n’est pas vdes prestataires. Si ceer vite. Il faudrait que ll’infirmière accepte (etucoup.’’
ather than patiennancement ce que ça atients. Passer au forfucun des deux ne man a tout le temps des Quand on a facturé etent était au forfait dan
as des patients. Ce n’eplus que la maladie, il
ns nos études. Toute l
sciplinary i.e. nurse) to pro
omicile, lorsqu’elle ne fmenclature). Ce qui s
à l’infirmière indépendses en milieu rural.’’
different primary e difficulties itent, je pense qu’aucau forfait, nous on est dans l'autre maison la mutuelle nous envomaison médicale…"
d to patient select voir 20 patients pour leurs soins. Les infirmvraiment payé. On dép
e sont des services intéla personne soit déjà àt arrive) à le laver. Le
nt oriented change. Notre rémunéfait ? Dans notre systèrche. Dans notre quarproblèmes, parce qu’it que la mutuelle nousns une autre MM… Puest qu’en médecine l y l’habitat et les famia journée moi, je suis
207
ovide
fait e fait ante.
care
un des à
oie la
ction que
mières pend égrés, à
ération ème, rtier, il ils sont s uis, le
lles dans
208
Threat
Chronic care
le pa
‘’Ona un psycnome
Crit’’ Poune fait qde m
Con« Cobénéenvanousplus pas o
Soc‘’ Mosont à l’ASplus
Opp
e
aradoxe.”
a un système de sécfossé qui va se creus
chosocial où tant le méenclature pour la prise
teria are ill adaptur les insuffisants rénaMRS ne peuvent pas
que le MG puisse se remobilité, lorsque la pers
ntrol of the paymoncernant les forfaits, léficient du forfait sont vahissant et dégradant. s, GP à recontacter le marcher. « Oui, elle nouvrir la porte. Ce son
cial worker out ooi je n’ai pas la chance
accessibles. C’est quS comme j’ai accès à un assistant, c’est l’ac
portunities
urité sociale qui couvrser par rapport aux inéédecin que d’autres poe en charge des patien
ted to some situaaux, il y a des limites, être dans ces trajets dendre au domicile. Le sonne est en MRS, el
ment system les mutuelles font leurvisitées par l’infirmièreTrès souvent, le forfamédecin conseil, en d
ne m’a pas ouvert ». Fnt des situations invrai
f reimbursemente de travailler au forfaitelque chose qui me ml’infirmière, au kiné. Q
ccueil, qui essaie …,’’
re pas mal de choses égalités sociales. Par rourraient consacrer dunts de longue durée ?
ations qui sont absurdes. Le
de soins, parce que lefait que les trajets de le ne peut pas bénéfic
r travail mais, très soue de la mutuelle. Les pait est rabaissé de mandisant, c’est quoi ces horcément, elle ne vousemblables. »
t system t et je ne travaille pas
manque cruellement. JQui fait ce travail-là che
KCE Report 1
mais j’ai l’impression rapport au soutien u temps, mais existe-t-’’
es personnes qui sont e remboursement est l
soins soient liés à la ncier du trajet de soins
vent les patients qui patients trouvent ça trènière inopportune. C’ehistoires, le patient ne us a pas ouvert, elle ne
dans un endroit où leJ’aurais envie d’avoir aez nous ? On travaille
192S
qu’il y
-il une
dans ié au notion ’’.
ès est à
sait e peut
s AS accès e à 4
KCE Reports 19
4.3.8. Reformservice
At present, thefees for specifor (over)produNew payment quality of chrservice. A shpatient-based care around th• In general
allocated to
“Ce n’est p• It already e
current sys
“Ik denk dpsychiaters
“Quand onreprésentedémence, pose le diextension,
• But lump participants
“La concethérapeutiqComment rêtre bien d
“Payer au c’est une risque de d
• However, t
92S
m proposal 8: moe-based to a teae larger share ofific services. Thiuction, and againsystems based
ronic care, focushift from a provsystem requires
he patient. practice there is
o a team
pas encore un forfexist some examstem
dat we een exces. Ze hebben dat
n parle de forfait, ent un diagnostictel qu’il a été coniagnostic, et qui le faire vers d’autsums allocated s
ertation en psychques, mais ce n’répartir entre les
défini, c’est très dif
niveau d’une éqéquipe ad hoc, c
dispute sur le partthese lump sums
oving froma indiam and patient-bf payments in pris system providnst delegation o
d on capitation csing more on t
vider and servics a parallel shif
already 20 perce
fait par équipe”(SGples of good prac
llent voorbeeld inzelf gevraagd” (S
il y a dans la nomc d’équipe. Je pnçu l’année derniè
est financée. Otres organisationsto a team can c
hiatrie, ça a dé’était pas spécialdifférents particip
fficile” (SGM2)
quipe qui soit strcomme en consutage” (SGM2) are not precisely
ividual provider abased payment srimary care are pdes de facto incf tasks.
can help to imprthe patient than e-based to a te
ft in the organiza
ent of lump sums,
GM2) ctices of capitatio
n art 107 hebbeSGM1)
menclature des apense au diagnoère. C’est une éq
On pourrait imagins” (SGM2) create tensions b
émarré avec les lement facile à epants de l’équipe.
ructurellement soultation oncologiq
targeted to tasks
Chronic car
and system provider centives
rove the on the
am and ation of
, but not
on in the
n bij de
actes qui ostic de
quipe qui ner, par
between
projets exploiter. Ça doit
udée, si que MD,
•
•
••
e
“We zijn vanquasi nul naaaltijd goed geachterliggend
Actual payme
“Les soins paMG de travaTravailler aveparce qu’ellesd’autres profe
“Ik kan daar thuisverpleginforfaitariseren
Payment sysconsumption o
“Le paiementchronique. Lecommence à qui y travailleMM”(SGM2)
“Il faut définiatteindre, ce sous-consomm
Professional b There is poss
introduced
“Een ander gevan fee for sforfaitair werkwel heel wat betalingen. Voplossing. Bedat is ook wa
daag, op 10 jaaar 20% lump sumetarget zijn, niet
de opdrachten zijnent system by fees
alliatifs ne sont paailler avec ces ec des infirmièress sont tout le temessionnels aussi”(
bijtreden. De forng zijn forfaits pern”(SGM2) stems based on of health care ser
t à l’acte règle es MM au forfait, c
voir poindre, puisent, une sous-co
ir un certain nomqui est aussi un mation”(SGM2) bodies are often csibility for patient s
evaar is patiëntenservice dan heb kt dan heb je ze mt ervaring binnenVoor sommige paehalve dat we keet P7 zegt: ‘Wat d
ar tijd in de huisms gekomen. De
altijd duidelijk g”(SGM1)
s generates profes
as payés à l’acte.infirmières, elless payées à l’acte
mps stressées. On(SGM2)
rfaitairen system r dat. Wij pleiten
capitation presrvices
mal la problémc’est une superbesque ce ne sont ponsommation de
mbre d’éléments élément de répon
contrary to pay forselection when pa
nselectie. Als je wje graag zeer z
misschien liever gn het revalidatiesyathologieën is zer op keer de fou
doen jullie nu voor
sartsgeneeskundezwakte is dat ze
gebonden aan wa
ssional stress
C’est un rêve pos prennent le tee, c’est insupporn pourrait le faire
die we kennen daarvoor om verd
ent a risk of u
atique de la mae organisation, maplus que des idéa
soins dans cert
objectifs de quanse au problème
r quality ay for quality wou
werkt naar een syszieke patiënten, agezonder. We heysteem met forfa
zo’n ‘all in’ de gut gemaakt hebber ons harde geld?
209
e van e niet at de
our le emps. rtable,
avec
in de der te
under-
aladie ais on alistes taines
alité à de la
uld be
steem als je ebben aitaire goede en, en ?‘. We
210
hebben duis, die verlodoen, … eonze patiëneuro per jaweten het nhelemaal n
• There is a instance win HIV refe
“Ik vind diegelinkt ondmaar het financieringeen beetje.
“Il faut allepartie au objectifs de
Important notsuggested anchronic diseasocial/work reimbursemenimportant meapayment.
us te weinig datacoren gaat in de lan we volgen de onten gebeurt. Hoe
aar de mensen? Isniet. En men verw
niks uit.”(SGM1) need for transpar
we do not know wrence centres)
e link naar kwaliteder de vorm van moet meetbaar
gssysteem nog lo. Die link zou ik ze
r vers un systèmeforfait, mais aus
e qualité à atteind
te: the documend evaluated maase (simplifiedenvironment,
nts). This positioasures but adds
collectie. Die ook ades, waar mutuaoutcome niet op ve vaak ziet een ais dat 2x per jaar, owijst naar de jaarv
rent quality asseshat happens to th
eit heel belangrijkinidicatoren, niet zijn. Want eigen
os mogen staan eker proberen te i
e de paiement missi définir un cerdre” (SGM2)
nt “Priorité auxany measures f administration
financial accon paper does ns a proposal in r
nog dikwijls niet aliteiten ook niet vvan wat er uiteindidscentrum voor oof is dat 27x per javerslagen maar da
sment system forhe lump sums pe
k. Maar dan echt alleen kwaliteitsenlijk er zou geevan evaluatie. Daintegreren.”(SGM
ixte, en partie à l’rtain nombre d’é
maladies chrofor the persons n, integration cessibility me
not come back trelation to new w
Chronic care
verplicht veel mee delijk met onze 870 aar? We aar blijkt
r this (for r patient
kwaliteit evaluatie en enkel at mis ik 1)
’acte, en éléments
niques” with a in the
easures, to these ways of
e KCE Report 1192S
KCE Reports 19
Theme 5
Clinical inform
Strength
Electronic file “Ook het elektronisverpleegkundige ka “Als cel in Brabant verschillende disciphulpverleners kunnthuisverpleegkundigsterk beveiligd. Het
“Il serait bon, si on pour le social, pourcarte d’identité. »
Electronic file
“Elk uur van de dagdie ene patiënt. Zokan er een nieuw sdeze webapplicatiemoet sowieso aanloaan de verschillendkiezen om hiervoorde woon zorg centrmaken, om de stan
‘’ La chance est queson GP. J’ai pu avol’information sur merapports que je n’ai
92S
mation system(s)
enables personach dossier zorgt dat w
an de patiënt heel gep
werken we met een eplines heen (ontwikkelen mits een toegangsgen, kinesisten, diëtist krijgt meer en meer b
parle de dossier médr le psychologique. Av
enables smooth
g kan er gekeken wordo kan er snel rond de ttappenplan opgemaak
e naar de verschillendeoggen in het systeem.de disciplines, dus het r in te teken en daarmerum en de ziekenhuizend van zaken in de thu
e cette dame est connoir l’information. L’hôpes patients, moyennani jamais reçus ‘’
, including E-dat
alized care we de patiënt persoonlpersonaliseerd benade
-zorg plan, een elektrod in Brabant, dus loka
ssleutel daar op in kijketen,… Het wordt veel bekendheid.”
dical partagé, un dossvec un accès sécurisé
h communication
den naar de stand vantafel gezeten worden mkt worden indien nodige zorgverleners, maar. Dit e -zorg dossier o komt als extra op hunee te werken. Voor soen zijn wel sterk vrageuiszorg te kunnen opvo
nue dans le système dital a mis sur pied un snt leur accord. Cela m
ta
ijk kunnen helpen, de eren”(B1VL)
onisch dossier over deaal per provincie). Alleen, huisartsen, gebruikt, de webappli
ier dans lequel il y aué, du type de mycare
n flow
n zaken van zorg met met de verschillende pg. Er kan gemaild worr het is allemaal sterk bof plan wordt aangebodn eigen systeem en zeommigen is dit wel extrende partij om hiervan olgen.”(B2VL)
de l’hôpital, je suis réfésystème où je peux ave permet de voir une s
Chronic car
Wea
e e
catie en is
rait une place net, avec une
betrekking tot partners of rden vanuit beveiligd. Je den als extra e kunnen ra werk. Maar gebruik te
érée comme voir série de
A u“Tecdemefamilsprekverzw
Com“Comcontaom wond
Com“De oernstvan deigen
’’Optpatiearrêtalors
Tele“Teleziekerendop.”(
“Oui prenparaprécu
e
akness
niform care langhnische protocols zijnentie of andere psychlieleden, iedereen heeken dikwijls een ‘verscwakt.”
mmunication betmmunicatie verloopt viact te houden, verpleete weten met wie
dzorg.(B2VL)
mmunication acroverdracht van informt van de anamnese in de problematiek ontstanlijk vermeden had ku
timaliser l’outil dossierent à la sortie… Un extés, pour les raisons ss que cela peut poser
emonitoring emonitoring voor hartfenhuisopnames zijn, eeert niet. Het vergt me
(B2VL)
pour tout ce que l’on d à domicile, on peut mètres, ce qui peut êurseurs qui jouent u
guage is lacking nog simpel, maar proopathologieën) zijn ze
eft z’n manier en dikwijchillende taal’ wat de d
tween lines can bia een schriftje (heen egkundigen wisselen e hij nu contact m
ross line can be atie tussen de verschhet ziekenhuis werd o
aan, en zo heeft dit geunnen worden.”(B2VL)
r médical du patient poemple tout bête seraituivantes… parce qu’odes problèmes.’’ (inte
falen loopt al enkele jaen het is financieel heeeer inzet van verschille
appelle le télémonitorraccorder le patient àêtre important pour leun rôle important da
otocols in verband meteker niet zo evident (…jls lijnrecht tegenoveredraagkracht van de fa
be improved en weer schriftje is ecelkaar vaak af. Dus z
moest opnemen in
improved illende hulpverleners ions niet meegedeeld, eleid tot verschillende )
our systématiser l’infort d’ajouter une case poon ne pense pas automrview)
aren, het blijkt wel niet el erg duur, het brengtende figuren. Het tota
ring à domicile, tous ceà un système qui peutes insuffisants cardiaans la prévention de
t omgangsvormen (ze…)Dingen formuleren aelkaar.Hulpverleners milie en de patiënt ec
cht ondermaats), moezeer moeilijk voor de h
verband met bijvoo
is echt ondermaats. Dzo is het ook het gevoziekenhuisopnames d
rmation médicamenteour les médicaments matiquement à les info
dat er daardoor mindt dus niet echt op of hele kostenplaatje breng
es paramètres que le t enregistrer directeme
aques en raison des ie grosses aggravatio
211
eker bij aan
ht wel
ilijk om huisarts orbeeld
De olg die
use du
ormer,
er et gt niet
patient ent ses indices on. Le
212
Threat Unsafe data tra“Privacy van zo’n d
‘’C’est très positif, mpeut-être pas envie
‘’Il y a des balises i
Fear for contro‘’Vanuit de huisartsals ‘big brother’’
Ethical problem« C’est très positif, peut-être pas envie
« Il y a des balises
ansport and privossier is ook een prob
mais ça posera beauce que ses données soi
mportantes à mettre’’.
ol (GPs) sen kijken we met argw
ms mais ça posera beauc
e que ses données soi
importantes à mettre.
vacy bleem”(B2VL)
oup de questions éthiient partagées.’’
.
waan naar kwaliteitsco
coup de questions éthient partagées.
» (B2FR)
ques. Parce que le pa
ontrole, we zien dat w
hiques. Parce que le p
Chronic care
télémsubs
Lac“(thuverbidie p“Menbij heniet gword
“Il y impomainplatedoss
atient n’aura
el een beetje
atient n’aura
OppUtilpres‘’ Ce un pedéjà assomainpatie
e
monitoring mériterait sidié… qu’il y ait une c
ck of compatibilitiszorg) Wij hebben inding, dus de huisarts
patiënt.”(B2VL) n zou wel moeten opteet ‘vitalink project’ (megebruikersvriendelijk e
den.”(B2VL)
a tout le temps des ose quelque chose mntenant qu’il y a le reforme eHealth et, pasier patient. » (B1FR)
portunities isation of algoritscription n’est pas toujours tou
eu du traitement et detrois ou quatre médic
ociées, si on a pas demntenant, il existe quandent…’’
d’être remboursé, mconvention pour le suiv
ty of informationelektronisch patiënte
s en thuiszorg kunnen
eren om te vertrekken edicatie schema’s).(apen werkt niet op lange
nouvelles initiatives, mais, pour les TIC, c’eréseau Santé Wallonar ailleurs, beaucoup
thms to assess t
us les mois qu’il faudrae la maladie… Si on paments rien que pour
mandé l’avis du patiend même beaucoup d’o
ais en CIC, il n’y a vi du patient en CIC…
n systems endossiers maar dien niet elektronisch me
vanuit het medisch dopotheker) Inderdaad sy termijn, systemen mo
peut-être les Wallonsest vraiment un magn, mais depuis quelqu
p d’hôpitaux proposen
the quality/safety
ait revoir la médicationprend un patient diabé
son diabète, d’autres nt sur les mesures à moutils qui existent et qu
KCE Report 1
rien de spécifique q » (interview)
staan niet met elket elkaar communicere
ossier van de huisartsysteem naast systeemoeten op elkaar afgest
s n’aiment-ils pas qu’onifique exemple. J’apues années on parlent au GP d’avoir acc
y/adequacy of dr
n d’un patient, cela déétique, il est fréquent q
pour les pathologies mettre en place… maisui sont à la disposition
192S
qui est
kaar in en over
s zoals m is temd
on leur prends
e de la cès au
rug
pend qu’il ait
s n du
KCE Reports 19
4.3.9. Reformacross
Patient mediccare goals, labthe health promeans an obliprotected data• Central file
different pr
“... dat kunmoeten daopgeslagen
”Ik zou zebinnen eeworden.” instemming
• Such a sysprofessiona
“ - Dat is meen zwakteC’est souvprofession
• Some stakinformationdisciplinary
“Il faut pedonnées, cpas intéresquelque chcompris lespar rapport
• RAI data (l
92S
m proposal 9: shs disciplines cal records (at leb data, medicatioofessionals involigation to use coa exchange provies can be in a rofessional groups
n je toch opvangenata, als die van algn worden.”(SGM1
eggen: dit zou eeen periode van m
(SGM1) “Absg van anderen) stem gathering thal secret
misschien de Achile… - Angst voorvent un alibi, mqui veut preservekeholder groups n of patient daty, complementary
eut-être mieux cibce qui est importassantes pour conthose comme ça, s patients. Parce t au problème qu’ike in protocole 3
hared medical file
east the most ion, care plans) slved at the differompatible softwision. cloud which ma
s more easy (oppo
n door een dataregemeen belang z1)
en wettelijke verpmaximum 5 jaar
soluut.”’(SGM1)
he medical patien
lleshield van het sr Big Brother ? -
mais il faut parfoer un secret profes
oppose the exa which are ne and for quality iss
ibler ce qui doit ant et pas simplemtinuer les soins. Etout le monde peque les patients a’on touche à leur v) are an example
e across lines an
important data sshould be accessrent levels of ca
ware systems and
akes accessibilityortunity)
egister op te bouwijn in een register
plichting moetenr moet kunnen (observatienotitie
nt data is a threa
systeem. Het is zeSecret professio
ois faire confiancssionnel” (SGM2)
xchange and stoeeded for workinsues
être accessible ment des infos quiEt je pense que aeut se mettre d’acaussi ont des résvie privée” (SGM1of this (opportunit
Chronic car
nd
such as sible for
are. This d a well
y among
wen, dan r kunnen
zijn die behaald
e: ook
at for the
eker niet onnel… - ce à la ) orage of ng multi
comme i ne sont utour de ccord. Y
sistances 1). ty)
•
4
Tim(lrpaaa•
•
e
“Avec le R
“En omdat deRAI durven al
Patients need
“Het zou voorte geraken Parkeerkaarte
4.3.10. Reform pfacility anpurpose
The availability omprovement init(local or regionaregistration at procedures, the anonymously, coappointment of oand to provide fe At present w
purposes We should mu
“In België hebdat we geen op zich, laat zou ook wat vaak komt nudaarbij: instrevolueren naaof iemand anzijn mijn patië
“En ook hier wprimary care,
RAI, ils sont entho
e RAI ook vanuit els voorbeeld geve
d access to open r
r de patiënten ookom bij verschill
en, kindergeld, en
proposal 10: aggnd local system l
of data on the catiatives at the local). Conditions f
practice levelappointment o
ompetences withorganisations wieedback. we lack good qua
uch more focus on
bben we een probkijk hebben op dstaan naar multexplicieter zijn, d
u een pathologie rumenten rond ar systemen dat znders, dat zij echt ënten.
weer vind ik een het gaat over d
usiastes”(SGM1)
een geintegreerd en”(SGM1) rights in the health
k mogelijk moetenlende instanties
n zo.”(SGM1)
gregated patient levels for quality
are provided is acal (practice) anfor implementatil, user-friendly of a third party hin the primary cith competencies
ality aggregated
n process indicato
bleem dat daar noe prevalentie, de ti-morbiditeit. Dusdat we ook beho
in ons land voopatiëntenregister
zorgverstrekkers, oinventarissen beg
beetje te eng als de kwaliteitsbewak
d concept denkt. Ik
h system
n zijn om aan hunrechten te ope
data at health y management
condition for qund intermediate leion are the acc
and safe upto collect the
care team and/os to analyze the
data for manage
ors
og voor komt en incidentie van zi
s procesindicatoreoefte hebben aanor? En ook het ars. Dat we moof dat nu de huisaginnen maken van
men hier enkel nking in het circuit
213
k zou
n data enen.
uality evels
curate pload
data or the e data
ement
dat is iekten en. Ik
n: hoe aspect oeten arts is n: wie
neemt t ook,
214
waarin natheel het cir
Theme 6 Accessibility oStrength
Easy hospitali“Binnen ons zorgsydirect naar een zieksnel). Kinderen kueen ziekenhuisopna
Emergency lin“Een huisartspraktijgenoten ), er istelefoontoestellen idoordat er meerderruimte en onderstwachtzaal zit”(B1VL
Facilitator to im“Un service d’accodémarches. Pour nn’est pas en mesuarriver, ne va pas d’avoir un accompaMM est important. Atrès vite, on est dev
tuurlijk primary carcuit.”(SGM1)
of care
sation is often aysteem wordt er wel hekenhuis te kunnen gaannen het probleem vaame zeer snel plaatsv
ne within primaryjk waar er een assist ook een spoedlijnin het hele gebouw, -re huisartsen zijn in deteuning gegeven worL)
mprove access tompagnement a été mnos patients (souffranture d’aider le patient se faire comprendre,
agnateur psychosociaAu début, on ne devavenu des accompagna
are heel belangrij
solution to “criseel snel een oplossingan (dit in tegenstelling
an één van de ouders vinden.”(B2VL)
y care practice ente aan de telefoon n binnen de huisar- de huisarts kan one groepspraktijkaanwerdendan bijvoorbeeld
to care mis en place pour aidt d’hépatite C), il est tr
à avoir accès au spva devoir sortir de l’h
l, qui puisse faire le reit accompagner que leateurs de santé global
jk is. Patiëntcentr
sis situation at hg bedacht. Het is een e tot in Nederland, dit gniet aan, en in ons sys
zit-(ze hebben daar ortsenpraktijk : die anmiddellijk ter plaatseezig zijn: op die manie een soloarts die m
der le patient à réalisrès rare qu’il y ait un apécialiste hospitalier. hôpital (SDF, psychiaelais entre le milieu hoes patients souffrant dle. “
Chronic care
red over
Wea
ome” evidentie om gaat niet zo steem kan
opleiding voor activeert alle
e gaan,dit kan er kan er meer met een volle
ser toutes les aidant. Le MG Le patient va trique). L’idée spitalier et les
d’hépatite C et
Wai“Er iskrijgeontbrtekor
Fina‘’C’esune sconsfinanet pa
Acc‘’Par confrspécspécl’hôpavecs’ins
The“ L’acdialyfinanmultirétrod’équ
e
akness
iting lists for nurs een tekort aan chronen regelmatig vragen vreekt maatschappelijkrt.(B2VL)”
ancial Aspects hst l’aspect financier qusituation très précaire
stitue une grosse partiencièrement à toutes ceas assez riches pour p
cess to specializer rapport à la question rontés à un gros probl
cialistes en termes de cialistes hyperspécialispital, lié au mode de finc un problème d’accèstallent à leur compte.’
e specificity of ruccès aux soins (méde
ysé) n’est pas si simplencement prévu pour l’inidisciplinaire hospitaliè
ocession du montant, puipe mobile qui pourra
rsing homes nische zorgopvangmovan mensen die we ze
k iets om die mensen o
have an impact oui est dramatiquement, on a accès à certaine de la population qui
es aides. Ils ne sont papouvoir le payer eux-m
ed care de l’accès aux soins s
lème de délais de rendcommunication avec lsés. Ce que je sens, cnancement du systèms financier. Moi je sens’
ural area in acceecins spécialistes, le me en milieu rural (Luxenfirmière à domicile, loère (pas dans la nomepar l’équipe hospitalièrait organiser ce genre
gelijkheden - tekort aaelfs niet op wachtlijst kop te vangen- er is ech
on the access andt important. On a parlénes aides. Mais le coma besoin de soins chr
as assez pauvres poumêmes. ‘’
spécialisés, en région dez-vous, l’accessibililes autres professionn
c’est des médecins spée hospitalier et qui se s beaucoup de médec
essing i.e. nursinmaintien d’une activité embourg). Pour l’instanorsqu’elle ne fait pas penclature). Ce qui se fare, à l’infirmière indépde choses en milieu r
KCE Report 1
an woongelegenheid ,kunnen plaatsen – er ht een aanbod
d delivery of caré de précarité ; lorsqu’mmun du petit VIPO quroniques, n’ont pas acr pouvoir faire appel à
bruxelloise, nous somté des médecins
nels, des médecins écialistes qui sortent dmettent en cabinet pr
cins spécialistes qui
ng care professionnelle en étant, il n’y a pas de partie d’une équipe ait parfois, c’est une endante. Il n’existe parural.’’
192S
we
e ’on vit ui ccès à l’aide
mmes
de rivé,
ant
as
KCE Reports 19
Threat
92S Chronic car
Accouts‘’Quainfirmpatieschizvont granqu’ilsdamea pasvoisiprob
Diff ‘’Poune fait qde m
Acc‘’Poupar lasuited’autla priaéro
Contask‘’Poudeviecentr
Opp
e
cess to coordinaside capitation sand on n’a pas la chanmiers à domicile, il y a ents chroniques, avec zophrènes bipolaires cdemander 10€ pour led-chose, mais le probs ont besoin d’aide, dee, qui avait besoin de s de référent, c’est difn qui va passer deux flèmes de nomenclatu
ferent access criur les insuffisants rénaMRS ne peuvent pas
que le MG puisse se remobilité, lorsque la pers
cess to « family aur ce qui est de l’accesa nomenclature, tout l
e un coût énorme. Lorstres personnes, avec uise de médicaments, isols, la surveillance d
ntradiction betweks requested to hur ce qui est de la répoent moins accessible, re de l’information qua
portunities
tion activities (i.esystem nce d’être dans un forfune série de choses qdes troubles cognitifs
chroniques), … on este passage pour la prélème est de convaincr
e devoir payer en pluscollyre, ne pouvait pa
fficile. Certains disent, fois par jour à heure fire .’’
teria depending aux, il y a des limites, être dans ces trajets dendre au domicile. Le sonne est en MRS, el
aids» ssibilité aux soins, hore reste est assez chesqu’on est très précariun début de démenceil n’y a aucun remboures paramètres : prend
een GP working himorher onse aigüe aux situatiomais on lui donne tou
and il y a une situation
e. done by case
fait de MM et qu’on doqui ne sont pas prises, nos patients psychiat vraiment freinés parcparation des médicamre ces personnes, qui , parce que l’INAMI ne
as le faire (Parkinson, on peut le demander
ixe, … La liste est long
on the pathologqui sont absurdes. Le
de soins, parce que lefait que les trajets de le ne peut pas bénéfic
rmis les soins infirmierr. Une aide familiale toisé, le coût est très ba
e, on nous dit qu’il faudrsement prévu : les godre le poids, …’’
in solo practice
ons, on voit que le méujours le rôle central etn complexe.’’
manager) for pe
oit bénéficier de soins s en charge. Avec nosatriques (sauf ceux quice que les coordinationments. Ça ne paraît pa
ont déjà du mal à acce l’a pas prévu. Une amalvoyant, …). Lorsqà un voisin, mais qui gue. Ce sont souvent
y es personnes qui sont e remboursement est l
soins soient liés à la ncier du trajet de soins.
rs qui peuvent être preous les matins, c’est to
as. Mais dès qu’il s’agidrait passer pour surveouttes oculaires, les
and importance
édecin est surchargé, t il n’est pas très bien
215
ople
i sont ns as cepter autre u’il n’y est le des
dans ié au notion ’’
escrits out de it eiller
of
il au
216
4.4. The ad
1. Plan, Provide, Coordinate
3. Conduct Early IdentificaActivities
4. Support Patient/ FamilyEmpowerment (Incl. Self‐Mg
Develop/ revise individualizedpof care with patient/family
Provide services and suppo
Monitor and evaluate progres
Provide care coordination
Conduct screeningactivitie
Developbroad detection ski
Develop tools & provider skforpatientempowermen
Provide patientempowermservices & support
Empowerment ainfor
Continuum of c
A
dapted chronic
Care 2. Provide Acute Episode Response
Services
ation
y gt)
5
6. Conduct health promotion & prevention a
plan
ort
ss
Provide seamless/ integrated care
Provide acute episode response
services
es
ills
killsnt
ment CL
8. Design a dynamic Care Model
Theme 3 nd support of patient and mal caregiver
Theme 1: care across lines and within lin
Theme 6 ccessibility of care
c Care Model a
7. Health care system
. For each activity check the followingrequirements:
activities
APPROPRIATE WORKFORCE
TAILORED DELIVERY SYSTEM DESIGN
APPROPRIATE FINANCIAL INCENTIVES
QUALITY ASSURANCE
DECISION SUPPORT
LINICAL INFORMATION SYSTEMS
nes
and the relation
(Re) definiprofessio
Payme
Communicapati
Chronic care
n with the them
Theme 2 ng the interaction, the role ofonals and training of professio
Theme 4nt systems and influence on c
Theme 5 ation amongst health professent and the support of E‐data
e
es from the bra
f health onals
care
ionals & a
ainstorming se
ssions
KCE Report 1192S
KCE Reports 19
4.5. Belgia4.5.1. Belgian
Structure initia
SISD (Servicesde Soins à Dom
SEL (SamenwerkinEersteLijns gezondheidszo
GDT GeinDienst Thuiszo
CCSSD: CenCoordination et de SeDomicile (SIT)
f There are
annex). g One for th
92S
an coordinationn coordination s
als Siz
s Intégrés micile)
Geodelimto 13maxcareWallBrus
gsinitiatief
org)
Geodelim14 zone
Aver
ntegreerde org
GeodelimWallin Fl
ntre de de Soins
rvices à
Geodelimto casevecarethemto a “pilla
e 13 health zones i
he French-speaking
n structures andstructures
e M
ographically mited according 3 care zones:
ximum one per e zone in loniaf ― 2 in sselsg.
- Esuatpr- ES._ - Dth- S
ographically mited according
regional care es
rage 1/500.000
Coorg
so
ographically mited. Taken in lonia by SISD, anders by SEL
-de
-oraro
ographically mited according are zones: eral CCSSD per e zone, each of m being affiliated
particular ar” (catholic,
- sethaan
n Wallonia. Two S.
community, one “b
d programmes
ain function
Ensure a continuity of upport throughout the t the level of the patienroviders; Enhance the collabora.I.S.D. members; Promote multidisciplinDevelop collaboration e second line of care Support new initiativesoordination of healthcganizations
ocial map of providers
efines need of care wi
rganise and financeound complex patients
Coordinate the provrvices around chronicat they are able to st
nd with a better quality
.I.S.D. (GLS and S
icommunautaire” (fo
Chronic car
information and care process, both
nt and of care
ation between
nary concertation; between first and delivery; s. care + social care
ithin population
e MDO meetings s care
ision of care and cally ill patients, so tay longer at home y of life.
.I.S.D. Luxembourg
or both French-spea
e
Main characteri
Platforms for informaexchange between clevel of the health zo
Task definition by p2009
Integrated in appropr
Structured by health French) or independe
Formal recognition ofperson ensures that coordinated around t
These structures are
g) cover two health
aking and Dutch-sp
stics
ation, support, collaborare and services provnes.
programme from Flem
riate organizations
insurance companiesent structures.
f coordination as a speproviders’ interventionhe patient).
positioned at the seco
h zones, while 4 he
peaking communities
Filefr
ration and viders, at the
ASNIrecreg
mish Community FinReCo
ASNI
s (“mutualités” in
ecific role (one ns are
ond line. Their
ASfingo
ealth zones are cov
s).
inancing or egislative amework
SBL Financed by thHDI (federal level) ancognized by thgional government
nanced by the NIHDecognised by Flemisommunity
SBL Financed by thHDI
SBL Recognized and nanced by the regionaovernment.
vered by no S.I.S.D
217
he nd he
DI sh
he
l
D. (see
218
SIT: SameIntiatief Thuisverzorgin(CCSSD)
SEL (SamenwerkinEersteLijns gezondheidszo
Local GP Organis(Huisartsenkringede médecins gene
ASI
socianeut
enwerkings voor
ng
At >25.inhatake
gsinitiatief
org)
Geodelimregio
Aver
ations en / Cercles eralistes)
Geodelimleveareasevemun
Locacovethoupeop
alist, liberal, tral, pluralist…).
beginning .000
abitants, Later en over by SEL
-ca
-ca
ographically mited at 14 onal care zones
rage 1/500.000
Coorg soTa
ographically mited at local l: they cover the
a of one or eral nicipalities.
Threp
ally based: they er several usands of ple.
Th
are coordinator
are plan per patient
oordination of healthcganizations ocial map of providersasks from SIT + GDT
hey organize after-hopresent GPs at variou
hey provide comprehe
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care + social care
ours services and s levels.
nsive care.
e
intervention is free fo
Umbrella function of care coordinating funpatients
Task definition by p2009
Corporate group of Ghuisartsenkringen in Généralistes in Wallo
In every “organized gmultidisciplinary teamadministrative staff, a(paramedical, social…collaborate with sociaprofessionals. It follow
or the patient.
bringing organizationsnction for high care n
programme from Flem
GPs working in a givenFlanders, 35 Cercles
onia
group practice”, one finm with minimum two Gand other care provide…). The structure musal workers and mentalws a perspective of in
s together and + needing complex
TaSE
mish Community ReCo
n area : 90 des Médecins
ASfin
nds a GPs, ers st also l health tegrated care.
FinW
KCE Report 1
aken over in 2009 bEL
ecognised by Flemisommunity
SBL Recognized annanced by the NIHDI
nanced by Regioallonne and CoCof
192S
by
sh
nd
on
KCE Reports 19
4.5.2. Belgian
Structure initia
Care pathways
Innovative forms o
Palliative care pla
92S
n coordination p
als S
s DRasphR7
of care (P3) V
tforms Eg2iFWG
programmes fina
Size
Delimited by thRLM/LMN (the relevanarea corresponds tosubarea of thpreviously mentionehealth zoneRecommended 75.000<<170.000
Variable
Each platform covers geographic area o200.000 to 1.000.00inhabitants. 15 Flanders, 8 Wallonia, 2 Brussel, Germanophone,
anced by the NIH
Main functio
he nt a
he ed e).
Integrate care facross discipline(at home, in hosp
Allows the frail home with a good
a of
00 in in 1
Positioned as three lines. support to care pinformation, straining of formawell as volunteer
Chronic car
HDI
n
for chronic disease s and levels of care pital, etc.)
elderly to stay at d quality of life.
collaboration over Platforms provide
providers in terms of sensitization, and al care providers as rs.
e
Main character
Care trajectories aRLM/LMN. Their marole the GP plays iinitiated by CMG).
P3 projects are diveby SISD/GDT or MRelderly).
A strong characterisorganization of a cas
Each platform’s staff coordinator/s and a pare determined by thpsychologists, their space where first support. They adeveloped by the needs.
ristics
are strongly intertwiain characteristic is thin their organization (
erse. They are usually RS (nursing homes for
stic of many P3 projectse management funct
is compound with one psychologist. Coordinathe needs of the field. Ar work consists in pr
line care providers also contribute to platform in response
Financframew
ned with he central (RLM are
Financed
initiated r the
ts is the tion.
Financed
or several tion tasks As for the
roviding a can find projects
e to local
Financed
cing or legislwork
d by the NIHDI
d by the NIHDI
d by the NIHDI
219
lative
