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This article is published in a peer reviewed section of the International Journal of Integrated Care 1Volume 12, 29 May 20...
This article is published in a peer reviewed section of the International Journal of Integrated Care 2International Journa...
International Journal of Integrated Care – Volume 12, 29 May – URN:NBN:NL:UI:10-1-112966 / ijic2012-31 – http://www.ijic.o...
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International Journal of Integrated Care – Volume 12, 29 May – URN:NBN:NL:UI:10-1-112966 / ijic2012-31 – http://www.ijic.o...
This article is published in a peer reviewed section of the International Journal of Integrated Care 6International Journa...
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Health care pathways and expert patients may 2012

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Health care pathways and expert patients may 2012

  1. 1. This article is published in a peer reviewed section of the International Journal of Integrated Care 1Volume 12, 29 May 2012Publisher: Igitur publishingURL:http://www.ijic.orgURN:NBN:NL:UI:10-1-112966 / ijic2012-31Copyright:Conference abstractHealth care pathways and expert patients: Do they improveoutcomes?/Rutas asistenciales y paciente experto: ¿mejoranresultados?M. Sans Corrales, GP, El Castell Primary Care Team [PCT], and Lecturer in the Department of Clinical Sciences, BellvitgeHospital, University of Barcelona, Barcelona, SpainL. Gardeñes Morón, GP, El Castell PCT, Barcelona, SpainC. Moliner Molins, GP, El Castell PCT, Barcelona, SpainI. Campama Tutusaus, RN, El Castell PCT, Barcelona, SpainS. Pérez García, GP, El Castell PCT, Barcelona, SpainM. Rozas Martínez, GP, El Castell PCT, Barcelona, SpainCorrespondence to: Dr. Mireia Sans Corrales, C/Marconi s/n, 08860 Castelldefels, Barcelona, Spain, E-mail: msans@ambitcp.catsalut.netKeywordsshared care, continuum of care, diabetes mellitus, heart failure, chronic obstructive pulmonary disease, atencióncompartida, continumm asistencial, DM, IC, EPOC 1IntroductionOne of the greatest challenges for health systems nowand in the near future is caring for people with chronicconditions [1]. This is going to involve not only provid-ing specific solutions for various groups of patients,but also working and, in particular, tackling challeng-ing situations in a different way. Any one organisationor professional group alone cannot give a ‘magical’ or‘universal’ answer to this problem. The approach mustchange, be multidisciplinary and subsidiary. It requiressettings to be developed in which organisations andprofessionals not just fulfil their duties but do so in acooperative, integrated manner, in an organisationalmodel that is different from the current one [2].In this context, in a territory of 124.65 km2, with catch-ment population of 180,000, one secondary carehospital and seven primary care teams (PCT), one ofwhich has formed a consortium with the local coun-cil, a joint project was designed to approach the mostcommon chronic diseases. The aims are to improvethe quality and continuum of healthcare provided,holding a first meeting between healthcare levels, pri-mary care (PC) and specialised care (SC), in orderto establish care pathways (CPs) for the followingdiseases: type 2 diabetes mellitus (DM2), heart fail-ure (HF), and chronic obstructive pulmonary disease(COPD).The overall objective of the project team was toimprove the follow-up of chronic patients, using the
  2. 2. This article is published in a peer reviewed section of the International Journal of Integrated Care 2International Journal of Integrated Care – Volume 12, 29 May – URN:NBN:NL:UI:10-1-112966 / ijic2012-31 – http://www.ijic.org/CPs and involving nurses in the education of theCOPD and HF patients, through an expert patient(EP) programme of the Catalan Institute of Health(ICS), that promotes self-care by exchanging knowl-edge between the EP and other participants withCOPD and HF.Description of the interventionWorking groups were established between profes-sionals in SC and PC (a GP and a PC nurse). During2010, these groups had regular meetings with othersinvolved in the care pathways to establish the actionprotocols, based on clinical practice guidelines, andthese were then presented to the rest of the PC andSC professionals.In the team, the following specific objectives wereset: for COPD, to increase the percentage of patientswho, in the previous two years, have undergonespirometry and have been advised to give up smok-ing, and to decrease the number of admissions forexacerbations; HF: to increase the percentage ofpatients whose BMI has been measured in the pre-vious year and whose status has been categorisedaccording to the NYHA (New York Heart Association)functional classification, to visit patients under homecare 2–3 times per year, to achieve appropriate pre-scription of beta-blockers, to improve the monitoringof blood pressure (BP), and to decrease the numberof admissions for decompensation; and for DM, toincrease the percentage of patients with cardiovas-cular risk assessments, with two measurements ofweight and glycated haemoglobin (HbA1C )per year,and with acceptable control of HbA1C, blood pres-sure and BMI.For this purpose, meetings were held between themembers of the team in charge of the pathways,the management and the other health professionalsinvolved. The aim of the these meetings being to makeeveryone aware of the pathways, provide diseaseupdates and clinical follow-up; in which lists of patientspoorly controlled according to the assessment indica-tors and incidents were distributed.The outcomes achieved (Figures 1–5) are comparedto those of 2009 (before the establishment of the carepathways).Increase in detection: 89 new cases HF (0.92–••1.45%), 211 of DM (5.28–5.99%), and 71 of COPD(1.96–2.58%).DM: increases in 6-month repeat assessment of••HbA1C levels (30.05–39.60%), REGICOR score(62–83.85%; p0.0001), weight (44.66–50.76%;0.925.281.961.455.992.5801234567HF DM COPDDetection (%)20092010Figure 1.  ••••39.12 32.97051015202530354045HbA1C7DM-patient with acceptable control (%)20092010Figure 2.  ••••p0.0001), BP (59.59–64.08%; p0.025) and BMI(41.63–47.37%; p0.01), as well as a decrease inthe percentage of patients with acceptable control(HbA1C7) (39.12–32.97%; p0.01).COPD: improvement in use of spirometry (55.96–••77.09%) and increase in the rate of cases foundwith an obstructive pattern (16.56–28%; p0.01),and increase in the percentage of patientsadvised in the previous 2 years to stop smokingfrom 33% to 68.83%, while there was also anincrease in emergency admissions for exacer-bations (1.9–2.02%) but this was not statisticallysignificant.HF: increases in patients with NYHA functional••class recorded (65.03–87.93%; p0.001), withweight measurements (16.78–45.52%; p0.001),receiving at least three visits/per year from a PCnurse (72.03–93.10%; p0.001), with prescrip-tions of beta-blockers reviewed/modified (16.22–54.60%; p0.001), and with BP measurements(26.57–34.05%), while there were decreases in thenumber of hospital admissions for decompensation(40.95–25.17%) and the mean length of hospitalstay (8.11–7.61 days).Nine sessions of the EP programme were carriedout for COPD and HF. Questionnaires were com-pleted at baseline, after 6 months and at the end of
  3. 3. International Journal of Integrated Care – Volume 12, 29 May – URN:NBN:NL:UI:10-1-112966 / ijic2012-31 – http://www.ijic.org/This article is published in a peer reviewed section of the International Journal of Integrated Care 365.03 72.0316.78 16.2226.5740.958.1187.93 93.131.0354.634.0525.177.610102030405060708090100NYHAclassHomecare3visits/yearWeightmeasurementsAppropriateprescriptionofβ-blockersBPmeasurementsHFadmissionsMeanhospitalstay(days)HF (%)20092010Figure 3.  ••••55.9616.561.977.09282.020102030405060708090Spirometry asrecommendedCases of obstructivepatternAdmissions forexacerbationsCOPD (%)20092010Figure 4.  ••••68.7528.79020.395.486.3624020406080100Accurate knowledge Self-care score Satisfaction (surveyin last session)Nine EPP sessions for COPD/HF-survey (%)BaselineLast sessionAfter 6 monthsFigure 5.  ••••the intervention: accurate knowledge 68.75, 86.36 and90.0%, respectively; European Heart Failure Self-careBehaviour scale: 28.7, 24.0 and 20.3%, respectively;and satisfaction questionnaire in the last session:95.4%.DiscussionSince the establishment of disease-specific carepathways, there has been an increase in the rates ofdetection and monitoring of the corresponding threediseases.With regards to DM, it should also be highlighted thatthere was an increase in compliance with the protocolagreed between PC and SC, improving the 6-monthlymeasurements and recording of glycated haemoglobinlevels, weight, and blood pressure, as well as calcu-lation of BMI and assessment of cardiovascular risk.On the other hand, it may seem surprising that therewas no increase in the percentage of patients with anacceptable control of their condition; indeed, the ratedecreased. We attribute this to the increase in detec-tion of new cases since the establishment of the carepathway.As for HF, there was a notable the reduction in thenumber of hospital admissions for HF as well as theaverage hospital stay, which may be explained dueto the increase in follow-up home visits by the end ofthe year, better control of blood pressure, spectacularincrease in the review and modification of treatmentwith beta-blockers and monitoring of weight as an indi-cator of possible clinical worsening.In the case of COPD, we highlight the increase in therates of spirometry tests (in line with recommenda-tions) and detection of cases with an obstructive pat-tern, although the rate of emergency admissions forexacerbations did not significantly change.In addition, together with the care pathways, the EPprogramme of the ICS has had an impact: improving
  4. 4. This article is published in a peer reviewed section of the International Journal of Integrated Care 4International Journal of Integrated Care – Volume 12, 29 May – URN:NBN:NL:UI:10-1-112966 / ijic2012-31 – http://www.ijic.org/patient knowledge on their own disease and increas-ing self-care (lower scores on the European self-care scale indicating better self-care). In turn, thesetwo factors may also have helped achieve thereduction in the rate of the hospital admissions forHF. Finally, there was a notably high level of satis-faction among patients who participated in the EPprogramme.ConclusionsCare pathways are a valid tool for achieving coordina-tion between levels of care and increasing the involve-ment of professionals, leading to a clear improvementin process indicators. The EP programme does helppatients increase their understanding of their conditionand enable them to improve their quality of life.Conference abstract SpanishIntroducciónLa atención a personas con problemas crónicos consti-tuye uno de los retos más importantes que debe afron-tar el sistema de salud en los próximos años [1]. No setrata sólo de aportar soluciones específicas para difer-entes grupos de pacientes, sino de trabajar y abordarlas situaciones de manera distinta. Difícilmente una solaorganización o un solo grupo profesional pueden daruna respuesta “mágica” y “universal” a estas nuevassituaciones. El abordaje debe ser diferente, multidisci-plinar y subsidiario, exige escenarios donde cada orga-nización y profesional haga lo que le toca hacer pero sehaga también de manera cooperativa, integradamente,en un modelo organizativo distinto al actual [2].De ahí que en un territorio de 124,65 km2, 180.000 habi-tantes, 7 Equipos Atención Primaria (EAP), 1 Hospital desegundo nivel y 1 EAP consorciado con el Ayuntamiento,se diseñó un proyecto común de abordaje a la patologíacrónica más prevalente, para mejorar la calidad y elcontinuum asistencial, celebrando una primera reuniónentre niveles asistenciales atención primaria (AP)- aten-ción especializada (AE), con el objetivo de elaborar rutasasistenciales (RA) de las siguientes patologías: diabetesmellitas tipo 2 (DM2), insuficiencia cardíaca (IC), enfer-medad pulmonar obstructiva crónica (EPOC).Así mismo, el equipo tuvo como objetivo mejorar elseguimiento de los pacientes crónicos, a partir delas RA e implicar a enfermería en la educación delpaciente EPOC e IC, mediante el programa pacienteexperto (PE) del “Institut Català de la Salut” que poten-cia el autocuidado mediante el intercambio de cono-cimientos entre un Paciente Experto (PE) y el resto departicipantes con EPOC o IC.Descripción de la intervenciónSe organizaron grupos de trabajo con profesionalesde AE y AP (un médico y un diplomado en enfermeríapor EAP). Durante el 2010, dichos grupos realizaronreuniones periódicas con el resto de referentes derutas para elaborar los protocolos de actuación, basa-dos en guías de práctica clínica; los cuales fueron pre-sentados al resto de profesionales de AP y AE.En el equipo, se fijaron los siguientes objetivos: EPOC:aumentar porcentaje de pacientes con espirometríaúltimos 2 años, aumentar porcentaje pacientes conconsejo antitabaco últimos 2 años, disminuir el númerode ingresos por reagudizaciones; IC: aumentar porcen-taje pacientes con registro de Indice de Masa Corporal(IMC) último año, porcentaje pacientes con registroNYHA (New York Heart Association), realizar 2–3 visi-tas año pacientes en atención domiciliaria, adecuaciónde tratamiento beta-bloqueante, control tensión arte-rial, disminuir número ingresos por reagudización; DM:aumentar porcentaje pacientes con registro riesgo car-diovascular, 2 determinaciones de peso y HbA1C poraño, control adecuado HbA1C y tensión e IMC.Para ello, se realizaron trimestralmente con los refer-entes de las diferentes rutas del equipo, la direccióny el resto de profesionales sanitarios, sesiones depresentación de las rutas, de actualizaciones de laspatologías y de seguimiento clínico; en las cuales sedistribuían listados de pacientes mal controlados segúnindicadores de evaluación y recogida incidencias.Los resultados obtenidos (Figuras 6–10), se presentanen comparación a los del 2009 (sin rutas):Aumenta detección: 89 nuevos casos IC••(0,92–1,45%), 211 DM (5,28–5,99%), 71 EPOC(1,96–2,58%).DM: aumenta controles semestrales hemoglo-••bina glicada (HbA1C) (30,05–39,60%), REGICOR(62–83,85%; p0,0001), peso (44,66–50,76%;p0,0001), TA (59,59–64,08%; p0,025), IMC(41,63–47,37%; p0,01), disminuye porcentajepacientes control aceptable (HbA1C7) (39,12–32,97%; p0,01).EPOC: mejora cumplimentación espirometría••(55,96–77,09%) y de ésta con patrón obstruc-tivo (16,56–28%; p0,01), aumentan los ingresosurgentes por reagudizaciones (1,9–2,02%; no
  5. 5. International Journal of Integrated Care – Volume 12, 29 May – URN:NBN:NL:UI:10-1-112966 / ijic2012-31 – http://www.ijic.org/This article is published in a peer reviewed section of the International Journal of Integrated Care 5(26,57–34,05%), disminuye número ingresos hos-pitalarios por descompensación (40,95–25,17%),disminuyendo estancia media hospitalaria (8,11–7,61 días).Realizadas nueve sesiones del programa PE paraEPOC, IC. Encuestas al inicio, a los 6 meses y en laDetección (%)0,925,281,961,455,992,5801234567IC DM EPOC20092010Figura 6.  ••••39,12 32,97051015202530354045HbA1C7DM-pacientes control aceptable (%)20092010Figura 7.  ••••65,0372,0316,78 16,2226,5740,958,1187,9393,131,0354,634,0525,177,610102030405060708090100RegistroNYHAAtdom 3visitas/añoControl TAPeso Adecuacióntratamiento β-bloq.Núm.ingresospor ICEstanciamedia hosp.IC (%)20092010Figura 8.  ••••significativo), aumenta el porcentaje de númerode pacientes con consejo antitabaco del 33% al68,83% en los últimos 2 años.IC: aumenta registro clasificación funcional NYHA••(65,03–87,93%; p0,001), peso (16,78–45,52%;p0,001), pacientes con mínimo de 3 visitas/año por EAP (72,03–93,10%; p0,001) y adec-uación tratamiento betabloqueante (16,22–54,60%; p0,001), control tensión arterial (TA)55,9616,561,977,09282,020102030405060708090Cumplimentacióncorrecta espirometríaCon patrónobstructivoIngresos urgentes porreagudizacionesEPOC (%)20092010Figura 9.  ••••68,7528,79020,395,486,3624020406080100conocimientoscorrectosescala europeaautocuidadoencuesta satisfacciónúltima sesión9 Sesiones Programa EP EPOC/IC. Encuestas (%)InicioÚltima sesióna los 6 mesesFigura 10.  ••••
  6. 6. This article is published in a peer reviewed section of the International Journal of Integrated Care 6International Journal of Integrated Care – Volume 12, 29 May – URN:NBN:NL:UI:10-1-112966 / ijic2012-31 – http://www.ijic.org/última sesión: conocimientos correctos 68,75; 86,36 y90%; escala europea autocuidado (European HeartFailure Self-care Behaviour scale): 28,7; 24 y 20,3% yencuesta satisfacción última sesión: 95,4%.DiscusiónDesde la instauración de las RA cabe destacar elaumento de la detección y registro de las tres patologíaspara las cuales se han establecido las rutas.En cuanto a la DM, también hay que remarcar queaumenta la cumplimentación del protocolo consen-suado entre AP y AE mejorando los registros semes-trales de hemoglobina glicada, cálculo del riesgocardiovascular, peso, tensión arterial e índice de masacorporal, pero podría sorprender que no conlleve unincremento del porcentaje de pacientes con controlaceptable. Esta disminución del porcentaje la atribui-mos al aumento de detección de casos nuevos desdela implantación de la ruta asistencial.En referencia a la IC, llama la atención la reduccióndel número de ingresos hospitalarios por IC y tam-bién la estancia media hospitalaria, que se podríaexplicar por el incremento de visitas domiciliarias deseguimiento al año, el mejor control de la TA, el espec­tacular incremento de la adecuación del tratamientobetabloqueante y el seguimiento del peso como indi-cador de descompensación.Respecto a la EPOC, destaca el incremento de la real-ización correcta de espirometría y detección de patrónobstructivo, aunque se mantiene prácticamente igualel número de ingresos urgentes por reagudizaciones.Asimismo y añadido a las RA, el programa PE delInstitut Català de la Salut también ha influido en lamejora de los conocimientos de los pacientes sobresu propia enfermedad, incrementando el autocui-dado, dado que una puntuación menor en la escalaeuropea de autocuidado significa justamente, a lainversa, mayor autocuidado. Estos dos factores tam-bién pueden influir en la reducción del porcentaje deingresos hospitalarios. También cabe destacar el altogrado de satisfacción de los pacientes que participa-ron en el programa PE.ConclusionesLas RAson una herramienta válida para la coordinaciónentre niveles asistenciales y la implicación de los pro-fesionales, produciendo clara mejora en indicadoresde procesos. El Programa PE ayuda a los pacientes aentender mejor su enfermedad y les permite conseguirmayor calidad de vida.References1. Bodenheimer T, Berry-Millett R. Care Management of patients with complex health care needs. Princeton: Robert WoodJohnson Foundation, 2009.2. Department of Health and Consumer Affairs of the Basque Government and Osakidetza. A Strategy to Tackle the Challenge ofChronicity in the Basque Country. 2010. [cited 2012 March 25]. Available from: http://cronicidad.blog.euskadi.net/descargas/plan/ChronicityBasqueCountry.pdf.

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