The underlying challenges of coordination of chronic care across Europe

Abstract

An effective response to the rising burden of chronic disease requires a health system environment that is conducive to implementing structured, integrated approaches to chronic disease prevention and management. This study presents some of the reported factors hindering the successful implementation of chronic care approaches in six European healthcare systems and focuses on processes to address these. We conducted 42 semi-structured interviews with key informants in Austria, Denmark, France, Germany, The Netherlands and Spain, representing the decision-maker, payer, provider and/or patient perspective. Despite differences among the healthcare systems studied, a shared set of barriers emerged. These included: (i) a continued focus on complications management and a failure to integrate risk minimisation and disease prevention along the spectrum of care; (ii) care fragmentation acting as a barrier to better coordination; (iii) a mismatch between intent, at national level, to enhance coordination and integration, and ability at regional or local level to translate these ambitions into practice; and (iv) a lack of structures suitable to promote proactive engagement with patients in the management of their own condition. Findings suggest successful implementation of chronic care across Europe will require cross-disciplinary collaboration, raising the profile of general practitioners and nurses, designing care explicitly around the needs of the patient, and the political will to carry forward these chronic care measures.

Keywords

Coordination international comparison health system care continuum Europe

Introduction

An effective response to the rising burden of chronic disease requires a health system environment that is conducive to implementing structured, integrated approaches to chronic disease prevention and management, hereafter referred to as ‘chronic care’.^1–3 Ideally, chronic care would include a consistent and comprehensive policy response to chronic diseases, supporting well-coordinated services in health promotion, primary prevention, early detection, treatment, disease and complications management, with particular attention on multimorbidities; this should be facilitated by information technology,⁴ adequate incentives, engaged health professionals and patients,⁵ and mechanisms for monitoring and evaluation.^3,6,7 However, health systems differ in terms of regulation, funding and delivery of healthcare, and the wider cultural, political, administrative and economic environments within which each system sits. It is our hypothesis that these differences affect the implementation of chronic care policies. Systems with a tradition of patient choice of any provider, little or no enrolment of patients and that use fee-for-service as main payment method in primary care face the greatest challenges in implementing system-wide strategies to provide care for patients with chronic illness.⁸ In contrast, systems with strong primary health care are more likely to give greater attention to the management of people with chronic conditions and to obtain better results.⁹ In this study, we seek to further explore the barriers to successful implementation of chronic care, and ways of overcoming these barriers, in six European countries: Austria, Denmark, France, Germany, the Netherlands and Spain.

Understanding the country context for chronic care policies

The countries reviewed in this study were chosen to illustrate the range of approaches to funding and governing healthcare across Europe. All are equally committed to providing universal and reasonably equitable access to healthcare for their populations, but do so with different financing and governance approaches, as described in Table 1.¹⁰

Table 1.

Key features of health system financing and governance in Austria, Denmark, France, Germany, The Netherlands and Spain.

	Health system financing	Governance of the public health system
Austria	Largely funded through statutory health insurance contributions from employers and employees, complemented by taxation, out-of-pocket payments and voluntary health insurance.	Shared by central government, nine state governments and corporatist actors; responsibility for hospital sector mainly with the federal states
Denmark	Largely financed through taxation, collected at national and municipal level, complemented by out-of-pocket payments and a small contribution of voluntary health insurance	Shared by central government, regions and municipalities; regions and municipalities are largely responsible for organising healthcare
France	Largely funded through statutory health insurance, complemented by out-of-pocket payments, taxation and voluntary health insurance	Traditionally concentrated at national level with gradual decentralisation of (selected) governance functions to regional agencies
Germany	Largely financed from statutory health insurance, complemented by out-of-pocket payments, taxation and voluntary health insurance	Shared by central government, 16 state governments and corporatist actors; responsibility for hospital sector mainly with the federal states
The Netherlands	Mainly from mandatory health insurance, complemented by out-of-pocket payments, taxation and voluntary health insurance	Shared by federal and local authorities and corporatist actors
Spain	Largely funded through taxation, complemented by a small contribution of social security payments, out-of-pocket payments and voluntary health insurance	Responsibility for organising publicly funded healthcare rests largely with the 17 regions (autonomous communities); national government sets regulatory framework and allocates funding

Sources: Reproduced with permission from Ettelt et al., 2008;¹² Ettelt and Nolte, 2010;¹³ Thomson et al., 2009.¹⁴

We have previously reported how the countries in our study vary with regard to their vision for organizing chronic care and the extent to which broader healthcare reforms have been translated into strategic policies.¹⁰ In brief, all introduced strategies of national reach during the 2000s. These included financial instruments to strengthen cooperation between the different sectors of the health system. An example is the ‘reform pool’ in Austria, a financial instrument to promote the coordination of and cooperation between ambulatory and hospital care.¹¹ In Denmark, France and Spain, national strategic frameworks for chronic disease control and management enabled the development of service delivery models with a focus on prevention and patient education.¹⁵ In Germany, nationwide disease management programmes were introduced.¹⁶ In The Netherlands, chronic care has become a priority in healthcare policymaking, with a focus on national evidence-based care standards and quality indicators, the promotion of multidisciplinary care teams, patients’ self-management and the promotion of performance-based financing on the basis of bundled payments.¹⁵

This paper sets out to elucidate the factors influencing the perceived success in implementing chronic care within diverse European healthcare systems, drawing from a series of interviews with key informants involved in relevant decision-making processes in Austria, Denmark, France, Germany, The Netherlands and Spain.

Methods

Data collection

In the context of a European research project evaluating approaches to chronic care in Europe,¹⁰ we conducted semi-structured interviews with key informants involved in decision-making processes related to various aspects of chronic care in Austria, Denmark, France, Germany, The Netherlands and Spain. We approached individuals in senior positions who were established as developing, implementing or analysing chronic care initiatives, and who represented a balance of decision-maker, payer, provider and patient perspective. They were identified through purposive and ‘snowball’ sampling, drawing from an established professional network of international contacts¹⁷ and through project partners based in the six countries. Where appropriate, we explored the websites of agencies and organisations considered relevant to chronic care to identify further contacts. Potential interviewees were invited by email and provided with background information; key interview topic areas were then shared upon agreement to participate. Interviews were conducted by telephone between July and October 2010, using a semi-structured interview guide, each lasting approximately one hour. Two study participants declined to be interviewed in person but provided their answers in writing.

The interviews were mainly held in English but also in French, Spanish or German, at the request of the interviewee. Three researchers were present during each interview; one led the discussion (either CK or EN), a second person listened for key areas to explore further, and a third person took notes. The interview guide covered the following issues: (1) perceptions of the current strategic focus in relation to chronic disease from risk minimization to complications management (Figure 1), using an illustration of the population-based health management approach;¹⁸ (2) perceived successes and failures in chronic care, and why/by what criteria; and (3) perceived barriers to the development and implementation of chronic care, the subject of this paper. With permission of respondents, all interviews were recorded and transcribed.

Figure 1.

Population-based health management approach.²⁰

Data processing and analysis

We based our analytical framework on the policy triangle proposed by Walt and Gilson,¹⁹ highlighting the role of actors, context, processes in policy development and implementation.²¹ A range of external factors such as political, administrative, economic and other considerations influence these interlinked components.²² Interview data were processed and analysed using the principles of framework analysis, considered appropriate as it is explicitly relevant to applied policy research.²³ Two researchers (CK and EN) identified a preliminary list of key ideas and recurrent themes from an initial reading of the interview transcripts. These were recorded in a purposely-built matrix. Data were then gradually organized into categories, and a shared set of barriers emerged. The organisation of data, including illustrative quotes, under these emerging barriers and facilitators helped to describe and elucidate the data, interconnections between the data, and the generation of explanatory patterns. The London School of Hygiene & Tropical Medicine Ethics Committee granted ethical approval for the study.

Results

We conducted a total of 42 interviews with key informants, ranging from three in France to 11 interviews in The Netherlands (Table 2). The most frequent perspectives (16) captured by interviews was those of individuals outside the direct decision making process such as academics, professional associations, or expert panels. The next most frequently captured view was that of the regulator (government or regulatory agency) (14). We were also able to interview five individuals representing the payer and provider perspectives, respectively. Despite our best efforts to invite patient associations and other patient representatives for interview, we were unable to capture patient views in countries other than one in France and one in Spain.

Table 2.

Sectors represented by interviews in each country.

	AUS	DEN	FRA	GER	NET	SPA	Total
Sectors	Countries
Government and regulators (ministry of health, local government, regulators)	2	2	1	2	4	3	14
Payer (including statutory health insurance funds, local government)	2	–	–	1	2	–	5
Provider (GPs, professional associations, provider associations)	1	1	–	2	1	–	5
Patient (patient associations)	–	–	1	–	–	1	2
Other (including academics and other agencies)	–	4	1	3	4	4	16
Total	5	7	3	8	11	8	42

AUS: Austria; DEN: Denmark; FRA: France; GER: Germany; NET: Netherlands; SPA: Spain.

Four broad categories of barriers to chronic care emerged from interviews. They relate to (i) a continued focus on complications management and a failure to integrate risk minimisation and disease prevention along the spectrum of care; (ii) care fragmentation acting as a barrier to better coordination; (iii) a mismatch between intent, at national level, to enhance coordination and integration, and ability at regional or local level to translate these ambitions into practice; and (iv) a lack of structures suitable to promote proactive engagement with patients in the management of their own condition. We examine each category in turn.

Continued focus on complications management at the expense of disease prevention

The majority of respondents in each country noted that managing complications has remained the main focus of chronic care, with mention of some movement towards more systemic disease management. Risk minimisation and disease prevention, while considered essential by participants, have remained on the whole institutionally and ideologically distinct from other components along the care continuum:

It is not yet in our habits to consider that chronic disease is a public health problem [ … ] [which] is a question of medical culture. [ … ] I think that in France the culture, the medical or health culture, is more concerned on acute care than on prevention. [ … ] the health authority has organised a lot of information and prevention campaigns and they are communication campaigns, but communication is not prevention. (France)

Some linked the focus on treatment (at the expense of prevention) to historical developments, as for example in Germany, where the medical profession has traditionally had a strong influence on shaping care delivery, particularly in the ambulatory care sector.

We are very bad [at] prevention of chronic diseases in Germany [ … ] and the focus is maybe between diagnosis and disease management [ … ] public health in Germany is underdeveloped. [ … ] Since 1945 the medical sector [has been] strong. They gained power and influence. [ … ] It is power to have 253 billion Euros invested in the health system, less acute care means that there are losers in this area and that is not easy to manage. (Germany)

The traditional focus on treatment of disease and complications management is reflected in the way resources are being allocated. This factor was highlighted by several respondents as a major obstacle to strengthening disease prevention as an integral component along the care continuum.

In Austria the area of risk minimisation is still considered as less important -perhaps not in theory but certainly when it comes to finding financial means for those programmes. Approaches concerning disease management are starting to get some attention at the moment. Provisions for acute care are very good. (Austria)

The financing structure appears to pose particular challenges for systems that are based on statutory health insurance in which the insurer may have little incentive to more proactively engage in offering preventative programmes, as noted by respondents from Germany and The Netherlands. This was expressed by a key informant as:

The problem with primary prevention is that sickness funds are in competition [but] primary prevention [efforts] have to be not only targeted to our own insurees but also on the insurees of other sickness funds. So we are not very motivated to make big primary prevention programmes when we know that other organisations will take benefit from it and we have to pay for it. (Germany)

Similarly, another respondent noted: ‘[I]t is a question of financing: there are very cost effective interventions which are not implemented because health insurers [ … ] do not really see prevention as part of their remit [ … ]’ (Netherlands).

Aside from financial disincentives to better embed prevention services within an overarching approach to chronic care, one respondent also observed how prioritising disease and risk prevention may also require an acknowledgement of non-health sector concerns:

I would say that Denmark is between disease management and acute care. And not that much in risk minimisation. [ … ] This is due to the political situation right now [ … ] where everything you do is connected to whether you want to gain votes [ … ] and if you do risk minimisation then you tell people not to smoke and do more exercise, and on that you will lose votes because nobody wants to quit their smoking; but they do if they get [ … ] lung cancer, then they want acute care. [ … ] you have to focus on acute care because that is what is selling votes. (Denmark)

At the same time, the discussion is beginning to develop further in some settings:

[T]he Netherlands is good at the diagnosis phase and good at complications treatment [and] the last few years [they have been] gaining more interest in disease management … [Regarding] risk minimisation or prevention, the discussion is starting, the discussion of who is in charge of risk minimisation, the people themselves or local government or the health insurer … This is the discussion that runs now. (Netherlands)

However, even where preventive services are being offered and integrated within the delivery structure, the overall coordination of care between providers and across different levels remains a challenge, which we discuss further below.

There have been remarkable experiences [in disease management] in some regions [ … ] like the Chronic Care Plan in the Basque Country where many features of disease management have grounded their development. [ … ] [However overall] our healthcare system is typically ‘acute-oriented’, followed by far, by risk minimisation, a service well implemented in primary health care [ … ], with some screening services. The gap [between] primary health care and specialised care acts as a key barrier for continuity of patient care along the different episodes of chronic disease. [ … ](Spain)

Care fragmentation acting as a barrier to better coordination

A perceived lack of coordination at the primary and secondary care interface, and between the health and social care sectors, was highlighted by most respondents. For example, one respondent noted: ‘we have ambulatory care, hospital care, we have some services, public or private, in trying to do some preventive care but they are very disconnected and fragmented [ … ] (France).’

Other respondents explained how this disconnect can affect patients:

[C]aregivers are working autonomously and have their own ways of working [which are] not connected to each other. So many things are happening twice, or things are not happening [at all], and there is no real coordination in it. I think that a lot of patients are feeling very, very lonely in the health care system, especially if they have more than one disease [ … ] because they have to shop around, as we call it, and they have not one contact person, for example. (The Netherlands)

Concerns about how fragmentation affects those suffering from multiple health problems was attributed by some to the high levels of specialisation within systems and a perceived lack of communication, with potential implications for patient safety:

People having more than one disease [ … ] very often tell you they went [ … ] to some specialist, and the specialist is looking only at this specific disease and does not look right, does not look left, yes? Does not ask about which drugs they’re taking, about which other diseases [they have]. I mean, it’s really a bit frightening. (Austria)

The nature of this disconnect varies among countries. Respondents highlighted the well-documented separation between the ambulatory and hospital care sector, as well as the lack of a registration system for patients in ambulatory care, as major obstacles to better coordination.

The first thing is that we don’t have a system where people have to go to their GP before they go to a specialist. Everyone who wants and also anyone registered in a [disease management programme] can always decide not to go to a GP but go to a cardiologist whenever they want so if people are not happy with the care they get with their GP they always have ways to go to other doctors. It is because of that that we lose a lot of information about those patients. (Germany)

‘Loss of information’ was also identified as a challenge by other countries. A participant noted that ‘the information does not go as quickly or all the information does not go across the interfaces in the health system’ (Austria). It was noted that the introduction of an electronic health record (the e-card) from 2005 is expected to go some way to improving this situation. Similar observations about electronic health records (EHR) were made for The Netherlands, identifying these as an important step towards continuity of care. However, the use of different EHR systems makes systematic assessment and evaluation of data at a system level challenging:

[T]here’s the EPD (electronic patient dossier), and what we see in these care groups in the primary care setting that the parties that work together some already have one EPD so they work together with one electronic system, patient-based, and they write in the same system [ … ][but] there is not one system. Everybody is doing their best and trying their own system, in fact [ … ] (The Netherlands)

Mismatch between national policy intent and local implementation

Inadequately managed administrative decentralisation was identified by many respondents as a main obstacle to achieving better coordination between sectors. In Spain, the system of budget responsibilities was seen to make the alignment of health and social care difficult:

We have a very complicated political and governmental structure [ … ]; the national and regional governments [ … ] have the competencies for most things you can think of. But then we have councils [ … ] in charge of the whole social thing and they don’t manage the same budget and they don’t have the same bosses or interests. So there you have the big problem. (Spain)

In Denmark, the 2007 administrative reform led to the reorganisation of regions and municipalities, giving municipalities more responsibility for health. Specifically, the reform required municipalities to contribute 20% to healthcare funding so as to encourage them to increase preventative services and, ultimately, reduce hospitalisations. However, it was reported that municipalities were lacking a coherent framework to guide them in their new tasks, as well as support to develop competencies in health care. There is a concern that many of the resulting projects may not be sustainable and measureable, as explained by one respondent:

Following the administrative reform] the municipalities had a central place in [solving] problems of the healthcare sector. The municipalities [have the responsibility] to create new health centres [ … ] [designed to overcome] barriers to coordination [ … ] [However] municipalities do not have the competence and knowledge about health care. And there is no systematic development in this area; [ … ] it is dependent on learning from the regional level. [ … ] [Moreover] the Regions got most of the [earmarked] 600 million DKK. [ … ] We have ended up with a lot of different projects and I am not sure how they will evaluate the projects and [ … ] implement the best. (Denmark)

Such disjoint between intent, at national level, to enhance coordination and integration, and ability at regional or local level to translate these ambitions into practice was also reported by French participants. For example, the 2009 reform in France stipulated that patient education should form a mandatory component of chronic illness care. However, this stipulation was not accompanied by adequate resources to implement relevant initiatives on the ground. As one respondent observed:

Funding for patient education has only got limited or ad hoc financing [ … ] usually allocated for one year, and then [once the funding runs out] it is always put into question. The law now says that patient education is mandatory. However where the financing comes from is still not clear [ … ] The nursing profession is collectively in agreement with [ … ] developing and implementing patient education programmes but this is based on the assumption that they have money to do it and at the moment they don’t. (France)

Furthermore, the creation in 2010 of regional health agencies was aimed at ensuring that healthcare provision meets the needs of the population by improving coordination between ambulatory and hospital care and between health and social care services. Yet, respondents highlighted that this recent decentralisation tended to result in unclear responsibilities, further fragmented decision-making and disjointed care.

Barriers to active patient engagement

Existing incentive structures for health professionals were often seen to be ill-suited to encouraging patients to participate in managing their own condition:

The current financing system pays the actions of the professions. So it pays the doctor, it pays the nurse, but it doesn‘t pay working together and it doesn’t pay self-management of the patients. [ … ] it starts with the treatment of complications. (The Netherlands).

One other respondent noted:

[I]t’s a fee for service remuneration and physicians earn more money if they [do] more tests, rather than talking to the patient or doing something like a foot examination [ … ] And the other problem which we have, which I think especially for diabetes type two is very, very important [ … ] to communicate to the patient that they themselves have to contribute in some way to their disease management – that it’s not only the doctor and the nurses or whoever, but they themselves have to do something. And that proves in Austria also to be not so easy. (Austria)

A change in the incentive structure will however require a fundamental change in the overall ‘medical culture’ perceived as characteristic of the current approaches to providing care in some settings. In Austria, a participant describes the situation as follows:

Office-based physicians are lone fighters [ … ]we have to do something for the doctors to work more – to have more control on what they’re doing, and to get them to work more according to guidelines, and also to share some of the responsibilities. In Austria the practice nurses virtually don’t exist. We have nurses going to people who really need nursing at home, but they’re not really collaborating with the doctors. (Austria)

Processes proposed to overcome perceived barriers

Respondents were also asked to provide their views on how to overcome the chronic care barriers they had identified. Cross-disciplinary collaboration was cited as important, where key disciplines not only work together but also train together. As suggested by one interviewee:

[ … ] the most efficient trainings are those that bring together health and social professionals from a same area or region as they need to work together [ … ] for better chronic care. So when we have teams that are trained and where there are doctors, nurses, social workers, and all these people train together, then we move ahead much faster because that way they develop habits to include and consider other disciplines’ points of view and to work with others. (France).

Several respondents highlighted the core role of strengthening primary care through raising its profile where it was seen to be low, such as in Austria, where general physicians (GPs) are reported to have ‘no reputation and [ … ] earn very little’ (Austria). It was suggested that chronic care provision could be improved by making reimbursement not conditional on the provider delivering services (as is presently the case in countries such as Austria, Germany or France), increasing remuneration of GPs, and raising their professional profile.

Strengthening the role of nurses, developing practice nurses in countries like Austria where they ‘virtually don’t exist’ (Austria), and collaboration between disciplines could be achieved through paying nurses and doctors from the same funding sources and developing professional competencies and training with other disciplines in mind, as noted above.

Another recommendation was for care to be explicitly organised around the patient with multiple conditions, to adequately address the growing reality that ‘when you are talking about chronic diseases, a lot of the patients have more than one disease’ (Denmark). Again, education and training of health care professional were seen as core to addressing this:

[ … ] broadening the knowledge among doctors about chronic diseases, and making sure that when a patient is admitted to a hospital with diabetes and also with heart diseases, [ … ] the two departments work together. [ … Moreover] there are pathways you can [develop for] better coordination (Denmark).

This also involves strategic support of patients in their own care, making sure that ‘good quality of health care must be grounded on the preference of patients’ (Germany), doing so by earmarking ‘some money that can only be used for patient education’ (Denmark) and integrating health services and public health:

for chronic diseases, medical interventions are very promising, and we won’t get very far with the concept of patient education telling the patient what he/she should or should not do. This is something that patients do know. Here we need public health interventions to change behaviour at the population level (Germany).

Finally, a common thread running through recommendations was the need for political will to support chronic care measures, including convincing policy-makers of the importance of reforming the medical curriculum to reflect the burden of chronic diseases and multimorbidity, providing sustainable funding for disease prevention and other public health measures, planning for the evaluation of programmes and systems, as reflected in a linked paper,²⁴ shifting the remuneration system to facilitate collaboration across disciplines and raising the profile of key players such as GPs and nurses.

Discussion

This study provides insights into how representatives from different sectors in Austria, Denmark, France, Germany, The Netherlands and Spain view the policy context for chronic care in their country, and their perception of the challenges and opportunities for providing a strategic response to chronic disease. The barriers to chronic care reported here include a continued focus on complications management and a failure to integrate risk minimisation and disease prevention along the spectrum of care; care fragmentation acting as a barrier to better coordination; a mismatch between intent, at national level, to enhance coordination and integration, and ability at regional or local level to translate these ambitions into practice; and a lack of structures suitable to promote proactive engagement with patients in the management of their own condition.

It has been argued that the successful implementation of chronic care processes requires understanding of the inefficiencies in healthcare delivery and the existing disincentives for the patient or provider to receive or deliver the highest quality care, alongside an understanding of the relative cost-effectiveness of alternative treatments, and successes of different interventions in modifying individual behaviour.²⁵ As illustrated in this study, similar challenges will play out differently in different contexts, requiring each country or region to analyse which might be the most contextually and culturally appropriate approaches.²⁶

At the core for the development of such culturally appropriate approaches will be an understanding of the dominant belief system and the dynamics of decision-making within the healthcare sector. This will also require visionary leaders who are able to instil a strong and cohesive culture in health care and who commit to continuous care improvement,²⁷ for example by improving the evaluation culture.²⁴

Our findings contribute to the growing consensus on the need for a coherent, coordinated response to chronic disease that takes account of the various tiers and sectors, such as public health and social care²⁸ in the system and along the care continuum.^28,29 Health professionals exert a large degree of control in healthcare organisations and will be central to put policy into practice. Failure to engage them in any process of change or reform is likely to hamper sustainable change.^3,30 This will also require continued efforts at patient-centred and patient-involved approach,^3,31–33 the integration of disease prevention and health promotion components into health services,³⁴ for example, within care pathways and clinical guidelines.³⁵

There has been an increased demand for understanding, evaluating and comparing health systems due to concerns around high health spending, new patterns of investment in health systems, and pressures to identify models of good practice. However, as in many fields, there is a tendency to apply a relatively reductionist approach to understanding systems’ structures and components. What is required is to focus on the system as a whole, the complex interactions of its subsystems, and the norms, beliefs and vested interests drive the existing prioritized model of curative health care.^36,37

Limitations

The number and types of stakeholders interviewed for this study varied among countries, with patients groups most underrepresented. This was in part attributable to the possible reluctance of patient groups to communicate in English although interviews in the native language were offered. One other reason for failure to engage a broader group of patient representatives was the scope of what interviews sought to capture, which may have been perceived by some as too broad. We acknowledge the central importance of patient and family perspectives on these aspects of chronic care, and although we tried to capture these through patient group representation, our paper does not include information from patients directly. Thus, there is an inherent bias to the insights reported here due to the unequal number of representatives in the different sectors for all countries. We were also unable to include a broader clinical perspective, which might have brought multimorbidity into consideration, which might have highlighted other issues such as access to services and affordable care. Finally, there may have been some limitations in conducting telephone interviews as opposed to face-to-face interviews through absence of visual cues and other nonverbal data.

Conclusion

This qualitative study reports the results of interviews on the implementation of chronic care in six different European countries. The voice of decision-makers was most represented. We found four common sets of barriers, however each tended to exist in a way that was specific to the context. Ultimately, our findings indicate that to be successful in the implementation of chronic care across Europe, there is a need for cross-disciplinary collaboration, raising the profile of GPs and nurses, designing care explicitly around the patient, and the need for political will to carry forward these chronic care measures, but also shared learning between sectors and countries in a number of areas in the health system.

Footnotes

Acknowledgements

We would like to warmly acknowledge all study participants for sharing their time and expertise.

Funding

The DISMEVAL project was funded under the European Commission’s Seventh Framework Programme (FP7) (grant no. 223277).

Conflict of interest

The views expressed in this paper are those of the authors alone and the European Commission is therefore not liable for any use that may be made of the information contained herein.

References

Epping-Jordan

Pruitt

Bengoa

. Improving the quality of health care for chronic conditions. Qual Saf Health Care 2004; 13: 299–305.

Segal

Dunt

Day

. Introducing coordinated care (2): evaluation of design features and implementation processes implications for a preferred health system reform model. Health Policy 2004; 69: 215–228.

Nolte

McKee

. Caring for people with chronic conditions. A health system perspective, Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies, 2008.

Hofmarcher

Oxley

Rusticelli

. Improved health system performance through better care coordination, Paris: OECD, 2007.

Dubois

Singh

Jiwani

The human resource challenge in chronic care. In: Nolte

McKee

(eds). Caring for people with chronic conditions. A health system perspective, Copenhagen: World Health Organization 2008 on behalf of the European Observatory on Health Systems and Policies, 2008.

Busse R, Blümel M, Scheller-Kreinsen D, et al. Tackling chronic disease in Europe. Strategies, interventions and challenges. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2010.

Powell Davies

Williams

Larsen

. Coordinating primary health care: an analysis of the outcomes of a systematic review. Med J Aust 2008; 188: S65–68.

Busse R and Mays N. Paying for chronic disease care. In: Nolte E, Knai C and McKee M (eds) Managing chronic conditions: experience in eight countries. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies, http://www.euro.who.int/__data/assets/pdf_file/0008/98414/E92058.pdf, (2008).

Nolte E, Knai C and McKee M. (2008b) Managing chronic conditions: experience in eight countries. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies, www.euro.who.int/__data/assets/pdf_file/0008/98414/E92058.pdf (2008b).

10.

Nolte E, Hinrichs S and Consortium TDP. DISMEVAL. Developing and validating disease management evaluation methods for European healthcare systems. Santa Monica: RAND Corporation and DISMEVAL Consortium, 2012a.

11.

Bundesministerium für Gesundheit Familie und Jugend. Reformen aufgrund der Vereinbarung gemäß Art. 15 a B-VG über die Organisation und Finanzierung des Gesundheitswesens 2008–2013. Available at: http://www.ris.bka.gv.at/Dokumente/LrNo/LRNI_2013132/LRNI_2013132.pdf.

12.

Ettelt S, Nolte E, Nikolentzos A, et al. Decision-making in health care: Roles and responsibilities at local, regional and national level. London: London School of Hygiene & Tropical Medicine, 2008.

13.

Ettelt S and Nolte E. Funding intensive care – approaches in systems using diagnosis-related groups. Santa Monica: Rand Corporation and London School of Hygiene & Tropical Medicine, 2010.

14.

Thomson S, Foubister T and Mossialos E. Financing health care in the European Union: Challenges and policy responses. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies, 2009.

15.

Nolte

Knai

Hofmarcher

. Overcoming fragmentation in healthcare: chronic care in Austria, Germany and the Netherlands. Health Econ Pol Law 2012b; 7: 125–146.

16.

Ettelt S, Nolte E, Mays N, et al. Health care outside hospital. Accessing generalist and specialist care in eight countries. Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies, 2006.

17.

Nolte

Ettelt

Thomson

. Learning from other countries: an on-call facility for health care policy. J Health Serv Res Pol 2008a; 13: 58–64.

18.

Petersen

Kane

Beyond disease management: population-based health management. In: Todd

Nash

(eds). Disease management. A systems approach to improving patient outcomes, Chicago, IL: American Hospital Publishing, 1997.

19.

Walt

Gilson

. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan 1994; 9: 353–370.

20.

Petersen K and Kane D. Beyond disease management: population-based health management. In: Todd W and Nash D (eds) Disease management. A systems approach to improving patient outcomes. Chicago, IL: American Hospital Publishing, 1997.

21.

Walt

Shiffman

Schneider

. ‘Doing' health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan 2008; 23: 308–317.

22.

Leichter

. A comparative approach to policy analysis: health care policy in four nations, Cambridge: Cambridge University Press, 1979.

23.

Ritchie

Spencer

Qualitative data analysis for applied policy research. In: Bryman

Burgess

(eds). Analysing qualitative data, Oxford: Routledge, 1994.

24.

Knai

Nolte

Brunn

. Reported barriers to evaluation in chronic care: Experiences in six European countries. Health Policy 2013; 110: 220–228.

25.

Epstein

Sherwood

. From outcomes research to disease management: a guide for the perplexed. Ann Intern Med 1996; 124: 832–837.

26.

Shaw

Rosen

. Fragmentation: a wicked problem with an integrated solution? J Health Serv Res Policy 2013; 18: 61–64.

27.

Suter

Oelke

Adair

. Ten key principles for successful health systems integration. Healthc Q 2009; 13: 16–23.

28.

Humphries

Curry

. Integrating health and social care. Where next?, London: The King's Fund, 2011.

29.

The King's Fund. Briefing on the health and social care bill. London: The King's Fund, http://www.kingsfund.org.uk/sites/files/kf/briefing-health-social-care-bill-Jan2011.pdf) (2011).

30.

Ham

. Improving the performance of health services: the role of clinical leadership. Lancet 2003; 361: 1978–1980.

31.

Chewning

Bylund

Shah

. Patient preferences for shared decisions: a systematic review. Patient Educ Couns 2012; 86: 9–18.

32.

van der Weijden

Boivin

Burgers

. Clinical practice guidelines and patient decision aids. An inevitable relationship. J Clin Epidemiol 2012; 65: 584–589.

33.

Imison C, Naylor C, Goodwin N, et al. Transforming our health care system. Ten priorities for commissioners. London: The King's Fund, www.kingsfund.org.uk/document.rm?id=9100 (2011, accessed 13 October 2014).

34.

IOM. Primary Care and Public Health. Exploring Integration to Improve Population Health, Institute of Medicine of the National Academies: National Academy of Sciences, 2012.

35.

Knai

Brusamento

Legido-Quigley

. Systematic review of the methodological quality of clinical guideline development for the management of chronic disease in Europe. Health Policy 2012; 107: 157–167.

36.

Meadows D. Places to Intervene in a System. Hartland, VT: The Sustainability Institute, 1999.

37.

Smith

Hanson

. Health systems in low- and middle- income countries. An economic and policy perspective, Oxford: Oxford University Press, 2012.