Original Title: «Batera Zainduz»: aplicación de modelos de gestión de patología crónica en atención primaria, enfocados a la integración de la asistencia

Authors' objectives: The overall project goal is the implementation and review of management models of chronic patients, oriented to care integration. The main objective of the project is broken down into 5 specific objectives: • Systematic review of literature for chronic disease management organizational models. • Piloting implementation of a chronic disease management model in our environment. • Evaluating effectiveness of chronic disease management model using clinical and resource management indicators. • Comparison between actual vs. new model. • Evaluating of patients who received groupal education.

Authors' results and conclusions: In clinical outcomes, no major changes are detected, as expected after evaluating studies and with similar duration and characteristics. In the case of glycosylated hemoglobin, significant improvements were found in the target population in both the average (-0,35, p

Authors' methods: Design: quasiexperimental study that compares clinical and management outcomes of a group of patients that have been treated with chronic management models and a control group that belong to centers where they have been treated conventionally. Sampling: consecutive of convenience. Scope: health Centers of Gorliz-Plentzia and Mungia, in Uribe Shire (Bizkaia). Inclusion criteria: patients over 18 years old diagnosed with Type 2 Diabetes Mellitus. Exclusion criteria: patients without sufficient data collected, institutionalized residents or carrying an external control, temporary residents in the municipalities, patients with cognitive deficits and deaths in the period of the project. Variables: clinical variables (glycosylated hemoglobin, blood pressure, total cholesterol, LDL-cholesterol and weight), management variables (number of visits in primary care, emergency number, hospitalizations and external visits) and variables reported by patients (quality of life, satisfaction, impact and knowledge). Interventions: the project, with a 2 years duration, has implemented interventions in the 6 areas of CCM in two populations belonging to Uribe Region Primary Health Centers. During the first semester, pre-intervention indicators were collected and target and control populations and interventions were selected to carry on the project. During the 2nd and 3rd semesters the interventions were carried out and during the last semester, post-intervention indicators have been collected and analyzed. These have been the priorized and implemented interventions: 1. Community: agreements with main town halls (Gorliz and Plentzia), social services, pharmacies and local diabetics associations. 2. Health system organization: leadership of the project by directive staff of the region. Changes to enable collaboration between Primary and Specialist Care and promotion of interventions by including them in the «Contrato Programa». 3. Self-management support: design and execution of a structured education plan for patients and professionals. Creation of a Shared Care Plan. 4. Delivery system design: primary and Specialty Care integration: Type 2 diabetics directed by Primary Care doctors and endocrinologists work as consultants. Enhanced nurse continuity-care role. Simplification of visits protocol. Collaborative discussion of complex patient cases. Risk stratification. 5. Decision support: adoption of new Diabetes Guideline and new Preferencial Supply. 6. Clinical information system: shared Electronic Health Record. Call Centre: treatment reminder and reinforcement service.

Project Status: Completed

Year Published: 2012

URL for published report: https://www.euskadi.eus/contenidos/informacion/2013_osteba_publicacion/es_def/adjuntos/D_13_05_modges_cron%20Batera%20zainduz.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government