出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Evidence from the international literature is that the prevention and management of chronic diseases through integrated care should be primary care GP led supported by primary care specialists and secondary care specialist services. Primary care led services towards integrated care marks a transformational shift away from hospital centric services, which has traditionally dominated healthcare in many countries. The shift towards integrated primary care led services is now a strategic priority at Government level across European countries and elsewhere in effort to tackle the growing burden of chronic disease (Nolte & Knai). The emphasis on integrated care is to avoid fragmentation of services between primary and secondary care and to ensure the delivery of “the right service, at the right time, in the right place by the right team”. The aims of this paper is to systematically present the evidence on: (i) what works best towards an integrated approach to chronic illness management between primary and secondary specialist services; (ii) the effectiveness of best models of integrated care programmes; and (iii) how best to implement an integrated care programme into a national healthcare service (such as Ireland) drawing on international best practices. Methods : This desk based research was guided by the principles of conducting systematic reviews (Higgins & Green 2011; Centre for Systematic Reviews & Dissemination 2008). Inclusion criteria for papers were by population (adults) with chronic disease (respiratory, diabetes, musculoskeletal, cardiovascular); focus on integration (across healthcare boundaries); publication type (meta-review, meta-analysis, meta-synthesis, RCT, or evaluation study); all limited to a publication within 10 year period from 2005. Databases searched were MEDLINE, CINAHL, Cochrane Library and Grey Literature. From a total of 6,466 records screened 24 studies in 33 papers were included for review. For the quality appraisal process, studies were stratified and grouped according to study type. For RCTs, internal validity was assessed using the Cochrane Collaboration’s Tool for Assessing Risk of Bias, and external validity was assessed using the criteria adapted from Foy et al. (2010). For the quality appraisal of synthesis papers, the AMSTAR (Assessment of Multiple Systematic Reviews) was used. Results : This findings indicate that a primary care GP led approach to integrated care for chronic illness management works best. The critical components of integrated care were found to be (i) nurse/led specialist care in primary care with a link into secondary care with a role in scheduled patient care, self-management support, risk stratification, speciality support for primary care teams, and care co-ordination across services (ii) ) shared or centralised information systems between primary and secondary care services e.g. medical records, tracking and recall systems, disease registers; (iii) shared clinical decision support tools such as clinical guidelines. These components were found to be effective in promoting positive outcomes at clinical, process and service healthcare levels. Transforming chronic illness management through an integrated care programme into a national health service was found to need a phased and bottom up approach, starting with pilot sites and working towards larger scale implementation and evaluation. Discussion : The evidence from this review supports recommendations for primary care services and clinical care delivery. There needs to be a shift from ‘individual patient’ care to a population based philosophy and approach to chronic disease management with an added emphasis on primary prevention for health and wellbeing. Identification of high-risk population groups using risk stratification techniques followed with implementation of targeted interventions are needed. There needs to be an increase in the number of specialist nurses working across clusters of primary care practices in countries such as Ireland where hospital centric healthcare system dominates. Lessons can be learned from other countries currently operationalizing strategies for chronic disease management through integrated care approaches (Nolte & Knai 2015). Conclusion : A well-designed integrated approach to chronic disease prevention and management can lead to positive clinical, process and service utilization outcomes. The review is limited by inclusion of studies of mixed quality and reliance of papers only. Primary authors or leads on integrated care in various countries were not contacted for additional insights. However, the pattern of evidence was consistent across the range of studies offering some practical solutions at clinical, professional, organisational and systems level for implementing an integrated approach to chronic illness management. The evidence provides a basis for further research such as the development of a pilot phase study for implementing one or more of the critical components of integrated care with a longer term goal for up scaling this research to wider implementation and evaluation.
关键词：chronic disease ; integrated care ; primary care ; specialist nursing ; information systems
