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1.  A qualitative study of integrated care from the perspectives of patients with chronic obstructive pulmonary disease and their relatives 
Disease management programmes have been developed for chronic obstructive pulmonary disease (COPD) to facilitate the integration of care across healthcare settings. The purpose of the present study was to examine the experiences of COPD patients and their relatives of integrated care after implementation of a COPD disease management programme.
Seven focus groups and five individual interviews were held with 34 patients with severe or very severe COPD and two focus groups were held with eight of their relatives. Data were analysed using inductive content analysis.
Four main categories of experiences of integrated care emerged: 1) a flexible system that provides access to appropriate healthcare and social services and furthers patient involvement; 2) the responsibility of health professionals to both take the initiative and follow up; 3) communication and providing information to patients and relatives; 4) coordination and professional cooperation. Most patients were satisfied with their care and raised few criticisms. However, patients with more unstable and severe disease tended to experience more problems.
Participant suggestions for optimizing the integration of healthcare included assigning patients a care coordinator, telehealth solutions for housebound patients and better information technology to support interprofessional cooperation. Further studies are needed to explore these and other possible solutions to problems with integrated care among COPD patients. A future effort in this field should be informed by detailed knowledge of the extent and relative importance of the identified problems. It should also be designed to address variable levels of severity of COPD and relevant comorbidities and to deliver care in ways appropriate to the respective healthcare setting. Future studies should also take health professionals’ views into account so that interventions may be planned in the light of the experiences of all those involved in the treatment of COPD patients.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-14-471) contains supplementary material, which is available to authorized users.
PMCID: PMC4283082  PMID: 25277208
Integrated care; Continuity of care; Delivery of healthcare; Disease management programmes, Patient perspective; Relatives; Chronic obstructive pulmonary disease; Qualitative study
2.  Instruments to assess integrated care: a systematic review 
Although several measurement instruments have been developed to measure the level of integrated health care delivery, no standardised, validated instrument exists covering all aspects of integrated care. The purpose of this review is to identify the instruments concerning how to measure the level of integration across health-care sectors and to assess and evaluate the organisational elements within the instruments identified.
An extensive, systematic literature review in PubMed, CINAHL, PsycINFO, Cochrane Library, Web of Science for the years 1980–2011. Selected abstracts were independently reviewed by two investigators.
We identified 23 measurement instruments and, within these, eight organisational elements were found. No measurement instrument covered all organisational elements, but almost all studies include well-defined structural and process aspects and six include cultural aspects; 14 explicitly stated using a theoretical framework.
Conclusion and discussion
This review did not identify any measurement instrument covering all aspects of integrated care. Further, a lack of uniform use of the eight organisational elements across the studies was prevalent. It is uncertain whether development of a single ‘all-inclusive’ model for assessing integrated care is desirable. We emphasise the continuing need for validated instruments embedded in theoretical contexts.
PMCID: PMC4203116  PMID: 25337064
integrated care; systematic literature review; measurement instruments; organisational elements
3.  Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches 
Self-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.
We conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice.
Self-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture.
Although collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.
PMCID: PMC3621080  PMID: 23530744
Chronic illness; Disease management; Self-management support; Comparative study; Qualitative research
4.  Social organization of self-management support of persons with diabetes: A health systems comparison 
Identify important organizational elements for providing self-management support (SMS).
Semi-structured qualitative interviews conducted in two healthcare systems.
Kaiser Permanente Northern California and the Danish Health Care System.
36 managers and healthcare professionals in the two healthcare systems.
Main outcome measures
Elements important to providing self-management support to persons with diabetes.
Healthcare professionals’ provision of SMS was influenced by healthcare system organization and their perceptions of SMS, the capability and responsibility of healthcare systems, and their roles in the healthcare organization. Enabling factors for providing SMS included: strong leadership; aligned incentives; use of an integrated health information technology (HIT) system; multidisciplinary healthcare provider teams; ongoing training for healthcare professionals; outreach; and quality goals. Barriers to providing SMS included lack of collaboration between providers and skeptical attitudes towards prevention and outreach.
Conclusions and implications
Implementation of SMS can be improved by an understanding of the elements that enhance its provision: (1) initiatives seeking to improve collaboration and integration between providers; (2) implementation of an integrated HIT system; and (3) ongoing training of healthcare professionals.
PMCID: PMC3443944  PMID: 22839353
Denmark; diabetes mellitus; general practice; health system; international comparison; patient education; self-management support
5.  Self-Management Support to People with Type 2 Diabetes - A comparative study of Kaiser Permanente and the Danish Healthcare System 
Self-management support is considered to be an essential part of diabetes care. However, the implementation of self-management support within healthcare settings has appeared to be challenging and there is increased interest in “real world” best practice examples to guide policy efforts. In order to explore how different approaches to diabetes care and differences in management structure influence the provision of SMS we selected two healthcare systems that have shown to be comparable in terms of budget, benefits and entitlements. We compared the extent of SMS provided and the self-management behaviors of people living with diabetes in Kaiser Permanente (KP) and the Danish Healthcare System (DHS).
Self-administered questionnaires were used to collect data from a random sample of 2,536 individuals with DM from KP and the DHS in 2006–2007 to compare the level of SMS provided in the two systems and identify disparities associated with educational attainment. The response rates were 75 % in the DHS and 56 % in KP. After adjusting for gender, age, educational level, and HbA1c level, multiple linear regression analyses determined the level of SMS provided and identified disparities associated with educational attainment.
Receipt of SMS varied substantially between the two systems. More people with diabetes in KP reported receiving all types of SMS and use of SMS tools compared to the DHS (p < .0001). Less than half of all respondents reported taking diabetes medication as prescribed and following national guidelines for exercise.
Despite better SMS support in KP compared to the DHS, self-management remains an under-supported area of care for people receiving care for diabetes in the two health systems. Our study thereby suggests opportunity for improvements especially within the Danish healthcare system and systems adopting similar SMS support strategies.
PMCID: PMC3441680  PMID: 22697597
Self-management support; Type 2 diabetes mellitus; Health system; International comparison
6.  Predictors of Effects of Lifestyle Intervention on Diabetes Mellitus Type 2 Patients 
The Scientific World Journal  2012;2012:962951.
The main aim of the study was to identify predictors of the effects of lifestyle intervention on diabetes mellitus type 2 patients by means of multivariate analysis. Data from a previously published randomised clinical trial, which compared the effects of a rehabilitation programme including standardised education and physical training sessions in the municipality's health care centre with the same duration of individual counseling in the diabetes outpatient clinic, were used. Data from 143 diabetes patients were analysed. The merged lifestyle intervention resulted in statistically significant improvements in patients' systolic blood pressure, waist circumference, exercise capacity, glycaemic control, and some aspects of general health-related quality of life. The linear multivariate regression models explained 45% to 80% of the variance in these improvements. The baseline outcomes in accordance to the logic of the regression to the mean phenomenon were the only statistically significant and robust predictors in all regression models. These results are important from a clinical point of view as they highlight the more urgent need for and better outcomes following lifestyle intervention for those patients who have worse general and disease-specific health.
PMCID: PMC3349167  PMID: 22593714
7.  Something is amiss in Denmark: A comparison of preventable hospitalisations and readmissions for chronic medical conditions in the Danish Healthcare system and Kaiser Permanente 
As many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas for improvement. Prior work indicates that chronic care coordination is poor in the DHS, especially in comparison with care in Kaiser Permanente (KP), an integrated delivery system based in the United States. We investigated population rates of hospitalisation and readmission rates for ambulatory care sensitive, chronic medical conditions in the two systems.
Using a historical cohort study design, age and gender adjusted population rates of hospitalisations for angina, heart failure, chronic obstructive pulmonary disease, and hypertension, plus rates of 30-day readmission and mortality were investigated for all individuals aged 65+ in the DHS and KP.
DHS had substantially higher rates of hospitalisations, readmissions, and mean lengths of stay per hospitalisation, than KP had. For example, the adjusted angina hospitalisation rates in 2007 for the DHS and KP respectively were 1.01/100 persons (95%CI: 0.98-1.03) vs. 0.11/100 persons (95%CI: 0.10-0.13/100 persons); 21.6% vs. 9.9% readmission within 30 days (OR = 2.53; 95% CI: 1.84-3.47); and mean length of stay was 2.52 vs. 1.80 hospital days. Mortality up through 30 days post-discharge was not consistently different in the two systems.
There are substantial differences between the DHS and KP in the rates of preventable hospitalisations and subsequent readmissions associated with chronic conditions, which suggest much opportunity for improvement within the Danish healthcare system. Reductions in hospitalisations also could improve patient welfare and free considerable resources for use towards preventing disease exacerbations. These conclusions may also apply for similar public systems such as the US Medicare system, the NHS and other systems striving to improve the integration of care for persons with chronic conditions.
PMCID: PMC3258291  PMID: 22192270
8.  Health-related quality of life and self-related health in patients with type 2 diabetes: Effects of group-based rehabilitation versus individual counselling 
Type 2 diabetes can seriously affect patients' health-related quality of life and their self-rated health. Most often, evaluation of diabetes interventions assess effects on glycemic control with little consideration of quality of life. The aim of the current study was to study the effectiveness of group-based rehabilitation versus individual counselling on health-related quality of life (HRQOL) and self-rated health in type 2 diabetes patients.
We randomised 143 type 2 diabetes patients to either a six-month multidisciplinary group-based rehabilitation programme including patient education, supervised exercise and a cooking-course or a six-month individual counselling programme. HRQOL was measured by Medical Outcomes Study Short Form 36-item Health Survey (SF-36) and self-rated health was measured by Diabetes Symptom Checklist - Revised (DCS-R).
In both groups, the lowest estimated mean scores of the SF36 questionnaire at baseline were "vitality" and "general health". There were no significant differences in the change of any item between the two groups after the six-month intervention period. However, vitality-score increased 5.2 points (p = 0.12) within the rehabilitation group and 5.6 points (p = 0.03) points among individual counselling participants.
In both groups, the highest estimated mean scores of the DSC-R questionnaire at baseline were "Fatigue" and "Hyperglycaemia". Hyperglycaemic and hypoglycaemic distress decreased significantly after individual counselling than after group-based rehabilitation (difference -0.3 points, p = 0.04). No between-group differences occurred for any other items. However, fatigue distress decreased 0.40 points within the rehabilitation group (p = 0.01) and 0.34 points within the individual counselling group (p < 0.01). In the rehabilitation group cardiovascular distress decreased 0.25 points (p = 0.01).
A group-based rehabilitation programme did not improve health-related quality of life and self-rated health more than an individual counselling programme. In fact, the individual group experienced a significant relief in hyper- and hypoglycaemic distress compared with the rehabilitation group.
However, the positive findings of several items in both groups indicate that lifestyle intervention is an important part of the management of type 2 diabetes patients.
PMCID: PMC3251531  PMID: 22152107
9.  Effective population management practices in diabetes care - an observational study 
Ensuring that evidence based medicine reaches patients with diabetes in the US and internationally is challenging. The chronic care model includes evidence based management practices which support evidence based care. However, despite numerous studies, it is unclear which practices are most effective. Few studies assess the effect of simultaneous practices implemented to varying degrees. The present study evaluates the effect of fifteen practices applied concurrently and takes variation in implementation levels into account while assessing the impact of diabetes care management practices on glycemic and lipid monitoring.
Fifteen management practices were identified. Implementation levels of the practices in 41 medical centres caring for 553,556 adults with diabetes were assessed from structured interviews with key informants. Stepwise logistic regression models with management practices as explanatory variables and glycemic and lipid monitoring as outcome variables were used to identify the diabetes care practices most associated with high performance.
Of the 15 practices studied, only provider alerts were significantly associated with higher glycemic and lipid monitoring rates. The odds ratio for glycemic monitoring was 4.07 (p < 0.00001); the odds ratio for lipid monitoring was 1.63 (p < 0.006). Weaker associations were found between action plans and glycemic monitoring (odds ratio = 1.44; p < 0.03) and between guideline distribution and training and lipid monitoring (odds ratio = 1.46; p < 0.03). The covariates of gender, age, cardiac disease and depression significantly affected monitoring rates.
Of fifteen diabetes care management practices, our data indicate that high performance is most associated with provider alerts and more weakly associated with action plans and with guideline distribution and training. Lack of convergence in the literature on effective care management practices suggests that factors contributing to high performance may be highly context-dependent or that the factors involved may be too numerous or their implementation too nuanced to be reliably identified in observational studies.
PMCID: PMC2955017  PMID: 20858247
10.  Early detection of COPD in primary care -The Copenhagen COPD Screening Project 
BMC Public Health  2010;10:524.
Chronic Obstructive Pulmonary Disease (COPD) is among the leading causes of death in the world, and further increases in the prevalence and mortality are predicted. Delay in diagnosing COPD appears frequently even though current consensus guidelines emphasize the importance of early detection of the disease. The aim of the present study is to evaluate the effectiveness of a screening programme in general practice.
Subjects aged 65 years and older registered with a General Practitioner (GP) in the eastern Copenhagen will receive a written invitation and a simple questionnaire focusing on risk factors and symptoms of COPD. Subjects who meet the following criteria will be encouraged to undergo spirometric testing at their GP: current smokers, former smokers, and subjects with no smoking history but who have dyspnea and/or chronic cough with sputum.
The Copenhagen COPD Screening Project evaluates the effectiveness of a two-stage screening program for COPD in general practice and provides important information on how to organize early detection of COPD in general practice in the future.
PMCID: PMC2940916  PMID: 20809934
11.  Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system 
Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system.
Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models.
More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration.
More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.
PMCID: PMC2907761  PMID: 20374667
12.  Integration of healthcare rehabilitation in chronic conditions 
Quality of care provided to people with chronic conditions does not often fulfil standards of care in Denmark and in other countries. Inadequate organisation of healthcare systems has been identified as one of the most important causes for observed performance inadequacies, and providing integrated healthcare has been identified as an important organisational challenge for healthcare systems. Three entities—Bispebjerg University Hospital, the City of Copenhagen, and the GPs in Copenhagen—collaborated on a quality improvement project focusing on integration and implementation of rehabilitation programmes in four conditions.
Description of care practice
Four multidisciplinary rehabilitation intervention programmes, one for each chronic condition: chronic obstructive pulmonary disease, type 2 diabetes, chronic heart failure, and falls in elderly people were developed and implemented during the project period. The chronic care model was used as a framework for support of implementing and integration of the four rehabilitation programmes.
Conclusion and discussion
The chronic care model provided support for implementing rehabilitation programmes for four chronic conditions in Bispebjerg University Hospital, the City of Copenhagen, and GPs' offices. New management practices were developed, known practices were improved to support integration, and known practices were used for implementation purposes. Several barriers to integrated care were identified.
PMCID: PMC2834924  PMID: 20216953
quality of care; integration of healthcare; chronic conditions; chronic care model; rehabilitation; chronic obstructive pulmonary disease
13.  Lifestyle intervention for type 2 diabetes patients – trial protocol of The Copenhagen Type 2 Diabetes Rehabilitation Project 
BMC Public Health  2009;9:166.
Current guidelines recommend education, physical activity and changes in diet for type 2 diabetes patients, yet the composition and organization of non-pharmacological care are still controversial. Therefore, it is very important that programmes aiming to improve non-pharmacological treatment of type 2 diabetes are developed and evaluated. The Copenhagen Type 2 Diabetes Rehabilitation Project aims to evaluate the effectiveness of a new group-based lifestyle rehabilitation programme in a Health Care Centre in primary care.
The group-based diabetes rehabilitation programme consists of empowerment-based education, supervised exercise and dietary intervention. The effectiveness of this multi-disciplinary intervention is compared with conventional individual counselling in a Diabetes Outpatient Clinic and evaluated in a prospective and randomized controlled trial. During the recruitment period of 18 months 180 type 2 diabetes patients will be randomized to the intervention group and the control group. Effects on glycaemic control, quality of life, self-rated diabetes symptoms, body composition, blood pressure, lipids, insulin resistance, beta-cell function and physical fitness will be examined after 6, 12 and 24 months.
The Copenhagen Type 2 Diabetes Rehabilitation Project evaluates a multi-disciplinary non-pharmacological intervention programme in a primary care setting and provides important information about how to organize non-pharmacological care for type 2 diabetes patients.
Trail Registration registration number: NCT00284609.
PMCID: PMC2694179  PMID: 19480671
14.  A retrospective analysis of health systems in Denmark and Kaiser Permanente 
To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy.
Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability.
A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS).
Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.
PMCID: PMC2630928  PMID: 19077229

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