Impact of a high-risk multimorbidity integrated care implemented at the public health system in Chile

Zamorano, Paula; Muñoz, Paulina; Espinoza, Manuel; Téllez, A. Ruiz; Varela, Teresita; Francisco, Suarez; Fernández, María José

doi:10.1371/journal.pone.0261953

Cited by 11 publications

(8 citation statements)

References 13 publications

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“…These findings relate to the intervention purpose of having the PHC as the axis of chronic patient care, where tertiary care and mortality reduction reflect a greater control of multimorbidity achieved by the intervened patients. These findings are consistent with previous impact analyses of the MPCM on health system performance and health outcomes [ 28 , 29 ]. We highlight that this estimate is more reliable than previous impact estimates due to the minimization of bias achieved after the propensity score matching.…”

Section: Discussionsupporting

confidence: 92%

Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system

Zamorano,

Espinoza,

Varela

et al. 2023

BMC Health Serv Res

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Multimorbidity and patient-centered care approaches are growing challenges for health systems and patients. The cost of multimorbidity patients and the transition to a new care strategy is still sightly explored. In Chile, more than 70% of the adult population suffer from multimorbidity, opening an opportunity to implement a Multimorbidity patient-centered care model. The objective of this study was to perform an economic evaluation of the model from the public health system perspective.The methodology used a cost-consequence evaluation comparing seven exposed with seven unexposed primary care centers, and their reference hospitals. It followed three steps. First, we performed a Time-Driven Activity-Based Costing with routinely collected data routinely collected. Second, we run a comparative analysis through a propensity score matching and an estimation of the attributable costs to health services utilization at primary, secondary and tertiary care and health outcomes. Third, we estimated implementation and transaction costs.Results showed savings in aggregate costs of the total population (-0.12 (0.03) p < 0.01) during the period under evaluation. Costs in primary care showed a significant increase, whereas tertiary care showed significant savings. Health outcomes were associated with higher survival in patients under the new care model (HR 0.70 (0.05) p < 0.01). Implementation and transaction costs increased as the number of pilot intervention centers increased, and they represented 0,07% of the total annual budget of the Servicio de Salud Metropolitano Sur Oriente. After three years of piloting, the implementation and transaction cost for the total period was USD 1,838,767 and 393,775, respectively.The study’s findings confirm the purpose of the new model to place primary health care at the center of care for people with non-communicable chronic diseases. Thus, it is necessary to consider implementation and transaction costs to introduce a broad health system multimorbidity approach. The health system should assume some of them permanently to guarantee sustainability and facilitate scale-up.

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Section: Discussionsupporting

confidence: 92%

Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system

Zamorano,

Espinoza,

Varela

et al. 2023

BMC Health Serv Res

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“…Finally, limited and unstable electricity coverage further constrained the acceptability and feasibility of implementing chest X-Ray at DH. These findings highlight the complexity of the process of decentralization, that goes beyond the acceptability of services, and beyond the mere provision of services, with closer availability: decentralization of childhood tuberculosis diagnosis also touches on the capacity of a whole economic system to support this approach, and the capacity of end-users to take on the offer [ 39 ].…”

Section: Discussionmentioning

confidence: 99%

Acceptability of decentralizing childhood tuberculosis diagnosis in low-income countries with high tuberculosis incidence: Experiences and perceptions from health care workers in Sub-Saharan Africa and South-East Asia

Joshi,

De Lima,

Massom

et al. 2023

PLOS Glob Public Health

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Decentralizing childhood tuberculosis services, including diagnosis, is now recommended by the WHO and could contribute to increasing tuberculosis detection in high burden countries. However, implementing microbiological tests and clinical evaluation could be challenging for health care workers (HCWs) in Primary Health Centers (PHCs) and even District Hospitals (DHs). We sought to assess the acceptability of decentralizing a comprehensive childhood tuberculosis diagnosis package from HCWs’ perspective. We conducted implementation research nested within the TB-Speed Decentralization study. HCWs from two health districts of Cambodia, Cameroon, Côte d’Ivoire, Mozambique, Sierra Leone, and Uganda implemented systematic screening, nasopharyngeal aspirates (NPA) and stool sample collection with molecular testing, clinical evaluation and chest X-ray (CXR) interpretation. We investigated their experiences and perceptions in delivering the diagnostic package components in 2020–21 using individual semi-structured interviews. We conducted thematic analysis, supported by the Theoretical Framework of Acceptability. HCWs (n = 130, 55% female, median age 36 years, 53% nurses, 72% PHC-based) perceived that systematic screening, although increasing workload, was beneficial as it improved childhood tuberculosis awareness. Most HCWs shared satisfaction and confidence in performing NPA, despite procedure duration, need to involve parents/colleagues and discomfort for children. HCWs shared positive attitudes towards stool sample-collection but were frustrated by delayed stool collection associated with cultural practices, transport and distance challenges. Molecular testing, conducted by nurses or laboratory technicians, was perceived as providing quality results, contributing to diagnosis. Clinical evaluation and diagnosis raised self-efficacy issues and need for continuous training and clinical mentoring. HCWs valued CXR, however complained that technical and logistical problems limited access to digital reports. Referral from PHC to DH was experienced as burdensome. HCWs at DH and PHC-levels perceived and experienced decentralized childhood tuberculosis diagnosis as acceptable. Implementation however could be hampered by feasibility issues, and calls for innovative referral mechanisms for patients, samples and CXR.

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“…The implemented model has shown positive results in health services utilization [ 16 ] and the systematization of this experience t has served as a base for the national scale-up of a similar strategy [ 13 ]. This study exhibits the effect of a pandemic on implementing a complex intervention in the health care system.…”

Section: Discussionmentioning

confidence: 99%

Effect of COVID-19 pandemic on the implementation of a multimorbidity person-centered care model: A qualitative study from health teams’ perspective

et al. 2022

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The COVID-19 pandemic has abruptly changed care priority and delivery, delaying others like the multimorbidity approach. The Centro de Innovación en Salud ANCORA UC, the Health National Fund, and the Servicio de Salud Metropolitano Sur Oriente implemented a Multimorbidity Patient-Centered Care Model as a pilot study in the public health network from 2017 to 2020. Its objective was to reorganize the single diagnosis standard care into a new one based on multimorbidity integrated care. It included incorporating new roles, services, and activities according to each patient’s risk stratification. This study aims to describe the perception of the health care teams regarding the impact of the COVID-19 pandemic on four main topics: how the COVID-19 pandemic affected the MCPM implementation, how participants adapted it, lessons learned, and recommendations for sustainability. We conducted a qualitative study with 35 semi-structured interviews between October and December 2020. Data analysis was codified, triangulated, and consolidated using MAXQDA 2020. Results showed that the pandemic paused the total of the implementation practically. Positive effects were the improvement of remote health care services, the activation of self-management, and the cohesion of the teamwork. In contrast, frequent abrupt changes and reorganization forced by pandemic evolution were negative effects. This study revealed the magnitude of the pandemic in the cancelation of health services and identified the urgent need to restart chronic services incorporating patient-centered care in our system.

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Impact of a high-risk multimorbidity integrated care implemented at the public health system in Chile

Cited by 11 publications

References 13 publications

Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system

Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system

Acceptability of decentralizing childhood tuberculosis diagnosis in low-income countries with high tuberculosis incidence: Experiences and perceptions from health care workers in Sub-Saharan Africa and South-East Asia

Effect of COVID-19 pandemic on the implementation of a multimorbidity person-centered care model: A qualitative study from health teams’ perspective

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