Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analysis (MCDA)

Abstract

BackgroundEvaluation of integrated care programmes for individuals with multi-morbidity requires a broader evaluation framework and a broader definition of added value than is common in cost-utility analysis. This is possible through the use of Multi-Criteria Decision Analysis (MCDA).Methods and resultsThis paper presents the seven steps of an MCDA to evaluate 17 different integrated care programmes for individuals with multi-morbidity in 8 European countries participating in the 4-year, EU-funded SELFIE project. In step one, qualitative research was undertaken to better understand the decision-context of these programmes. The programmes faced decisions related to their sustainability in terms of reimbursement, continuation, extension, and/or wider implementation. In step two, a uniform set of decision criteria was defined in terms of outcomes measured across the 17 programmes: physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centeredness, continuity of care, and total health and social care costs. These were supplemented by programme-type specific outcomes. Step three presents the quasi-experimental studies designed to measure the performance of the programmes on the decision criteria. Step four gives details of the methods (Discrete Choice Experiment, Swing Weighting) to determine the relative importance of the decision criteria among five stakeholder groups per country. An example in step five illustrates the value-based method of MCDA by which the performance of the programmes on each decision criterion is combined with the weight of the respective criterion to derive an overall value score. Step six describes how we deal with uncertainty and introduces the Conditional Multi-Attribute Acceptability Curve. Step seven addresses the interpretation of results in stakeholder workshops.DiscussionBy discussing our solutions to the challenges involved in creating a uniform MCDA approach for the evaluation of different programmes, this paper provides guidance to future evaluations and stimulates debate on how to evaluate integrated care for multi-morbidity.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3367-4) contains supplementary material, which is available to authorized users.

Measures for the integration of health and social care services for long-term health conditions: a systematic review of reviews

“…sick leave) [22] Administrative burden [21] Service differentiation [33] Operational and organisational structure integration [15,33] Clinical integration [33] Other Extent of integration (Depth/level/degree of integration) [15,32] Implementation of integrated delivery, Plan-do integration [33] Care integration and chronic care [20] Processes Performance measures Quality: Perceived quality, quality standards [13,15,21,28,31], quality of care transistion [15], quality of care planning, performance management [15] Time spent in emergency/urgent care, length of wait [13], timeliness of assessments [22], timeliness of information transfer [15] Rates of patients leaving insurer [21] Adherence to process measures [27] Improved documentation [28] Patient, family and carer perspectives Satisfaction, experience, preferences met, involvement in decision making, incidents of complaints [13,15,20,21,23,[29][30][31][32]34] Level of empowerment and empathy [15,30,32], person centeredness, comprehensive care [20,24] Personal respect (dignity, confidentiality, autonomy, comfort with care provider) [15,34], compassionate care, preferred place of death…”

“…Costs of living at home, justice contacts [24], Vocational status [23] Health outcomes Clinical measures Mortality [21, 23-25, 27-29, 31, 32], Blood pressure [21], BMI [21], Medication [29], Complications [23], Symptoms (e.g. Head injury [23], pain and other [24]), symptom control [28], Cognition [23], co-morbidities [34]. Adverse events [23] Treatment adherence [26], Adherence rates [23] Condition specific clinical measures (Bowel related problems [28], Percentage healed, mean time to wound healing [28], HbA1c [21], Transmission (mother to child HIV) [26], Problems associated with substance dependence [26], biomarkers for chronic disease [34].…”

“…Social support [25] Resilience [24] Enjoyment of life [24] Patient: Other Activation and engagement [24] Autonomy [24], self-efficacy, self-management or empowerment [34], knowledge and understanding of condition [23,34] Total pain relief (brief pain inventory) [28] Burden of medication [24] Patient cognition/ cognitive function [25,29,30] Disease specific measurements (undefined) [29] Carers and family Carers' quality of life [23,25] Carer outcome (undefined) [23] Caregiver burden [23][24][25][29][30][31][32] Caregiver mood [25], caregiver strain, depressive symptoms or distress [30,34] Family relationships [26] Family involvement in care [15] Time spent caring [23] a Considered patient reported unless specifically reported as clinician reported family or carer perspectives of processes of care. Performance measures were included in seven reviews which predominantly consisted of quality-related measures assessing staff and patient perceived quality, quality standards [13,15,21,28,31], quality of care transistion [15] and, quality of care planning and performance management [15].…”

“…Function: Health and function [22], function (including physical performance test) [23], physical functioning [24], Functional decline [32], Self-sufficiency [24] Level of disability [23], Activities of daily living/dependency (Barthel Index) [27,28], Degree of disability or dependence in the daily activities of people who have suffered stroke (Rankin scale) [27] Glasgow Outcome Scale (brain injuries, grouping by degree of recovery) [23] Mental health and behavioural measures (clinician/caregiver rated)…”

“…Mood [23,29] Emotional state [23], worries, concerns and stress [34] Psychological well-being [24] Mental illness symptoms [26], Mental health [34] Depression and anxiety [25,29,31], Patient Health Questionnaire (PHQ) [23], Geriatric depression scale [28] Social participation/relationships [24] This review was not limited to a specific review design but aimed to provide a broad overview of measures used in the evaluation of integrated care. As such we did not systematically evaluate the methodological rigour of each review.…”