出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Risk adjustment variables for population stratification are based, primarily, on the burden of disease and the pattern of use of resources. They do not include other variables that, according to available evidence determines the complexity, such as coordination of care on a regional level, certain patient characteristics (adherence to treatments or visits, mental disorders, etc...) and, especially, socioeconomic, cultural, environmental and behavioural context. In Catalonia, a strategy for proactive identification of complex chronic patients (CCP) and, within these group, patients with advanced chronic disease and palliative care needs (CCP-ACD), by healthcare professionals in primary care, based on clinical judgment and broad criteria, encompassing clinical and psychosocial variables, combined with Clinical Risk Groups (CRG, a risk-adjustment tool and clinically-based classification system used to measure a population’s burden of illness) has been promoted by the Chronicity Prevention and Care Program (CPCP) from the Department of Health. To the best of our knowledge, this strategy of identifying CCP from combination of risk adjustment and clinical judgment is a pioneering and unique experience worldwide. Professional perspective of what defines complexity, as well as clinical and psychosocial criteria used for identification, may not be matching between physicians and nurses, so identification of people with chronic diseases and complex care needs based on different criteria might be needed. The objectives of this study are 1) to determine the agreement between physicians and nurses in a primary care setting in identifying patients with chronic diseases and complex care needs (CCP and CCP-ACD) and 2) to describe the frequency and distribution of CPCP criteria used in identification by physicians and nurses. Methods : Population-based cross-sectional study based on information contained in the morbidity database of Catalonia in 2015 and professional electronic medical records. Setting: three primary care urban practices placed in Sabadell (Barcelona) belonging to the Catalan Institute of Health (ICS). According to this database, population with CRG≥5 and older than 14 years old (24762 inhabitants) were reviewed and CCP and CCP-ACD were identified and coded in the Shared Clinical Record of Catalonia, a common technological platform accessible to all providers of public health network. Study population is that which was recorded by healthcare professionals as CCP and CCP-ACD in the Shared Clinical Record of Catalonia on 30th September 2015. We will characterize complex patients and compare the characteristics of people with and without chronic complex care needs, according to professionals’ criteria by using chi-square or t-student tests, as appropriate. To examine the variability in identifying people with chronic diseases and complex care needs, we will calculate percentage of agreement and concordance degree using the Cohen's Kappa statistic. Results : (progress report) The identification and data collection was carried out between 1st July and 30th September 2015. It is expected to have the results of the study in February 2016. Discussion : The data provided by this study might confirm the existence of low agreement between physicians and nurses in primary care when identifying people with chronic diseases and complex care needs using clinical judgment and broad criteria, encompassing clinical and psychosocial variables, making advisable, therefore, an inclusive identification strategy in order to avoid health care inequities in these patients. Conclusion : Not applicable
关键词：complex care needs ; advanced chronic patients ; palliative care needs ; complex chronic patients ; integrated health and social care
