La sanità in rete: un ponte tramedicina delle evidenze e mondo reale
Roberto Bernabei, M.D.Roberto Bernabei, M.D.Centro di Medicina dell’ Invecchiamento Centro di Medicina dell’ Invecchiamento
Università Cattolica del Sacro Cuore - RomaUniversità Cattolica del Sacro Cuore - Roma
XXVIII Seminario dei Laghi
I SERVIZI SANITARI IN RETEDAL TERRITORIO ALL’OSPEDALE
AL TERRITORIO
Gardone Riviera – Brescia, 20 ottobre 2006
Malato Anziano FragileMalato Anziano FragileComorbiditàPoliterapiaStato funzionaleStato cognitivoFunzione fisicaTono dell’UmoreStato socialeIncontinenza
Malnutrizione
Cadute
Osteoporosi
FR
AG
ILIT
A’
FR
AG
ILIT
A’
Con quale modello Con quale modello assistenzialeassistenziale
Con quale Con quale metodologiametodologia
Sperimentazione modelli Sperimentazione modelli innovativi in Italia (1990-innovativi in Italia (1990-
2006)2006)BergamoMonza
Vittorio VenetoVenezia
ChiavariArezzo
Regione Umbria
Roma C
CastrovillariRagusaRegione Sicilia
LecceBrindisiBariFoggiaAndria
Regione Basilicata
Olbia
Jesi, Macerata, PesaroRegione Marche
Regione Molise
Avellino
Pescara
Rovereto
1 2Odds Ratio
SolitudiSolitudinene
Età 65-74 75-84 85+
P. economiciP. economiciDiagnosi 1-2 3-4 5+P. ospedaliz.P. ospedaliz.
2004;57:832-2004;57:832-836836
OSPEDALE OSPEDALE
TERRITORIOTERRITORIO
Modello Modello OrganizzatiOrganizzati
vovo
VMDVMD
HEALTH SETTINGSHEALTH SETTINGS
(GP, Hospital, NH, HC)(GP, Hospital, NH, HC)
Organization CGA
ELDERLY PEOPLE
Hospital
Home
CARE PLAN
General Practitioner +Case Manager + Community Geriatric Evaluation Unit
Eligible
Community Geriatric
Evaluation Unit
(Case Manager)
General Practitioner
Nursing homeHospitalDay hospitalHome care
Bernabei et al, Br Med J 1998; 316:1348-51
* p < 0.01
* * * *
Bernabei et al, Br Med J 1998; 316:1348-51
Functional status after 1 year of follow-up
Institutionalisation(hospital + nh)
Months
Treated
Control
HEALTH SETTINGSHEALTH SETTINGS
(GP, Hospital, NH, HC)(GP, Hospital, NH, HC)
Organization CGA
interRAI
North AmericaCanada
US
Nordic CountriesIceland, Norway, Sweden, Denmark, Finland
EuropeNetherlands, Germany,
Switzerland, France, UK
Italy, Spain,
Czech Republic
AustralasiaJapan, South Korea, Taiwan, Hong Kong
Australia, New Zealand
Middle East
Israel
Home Care
BERGAMO
District 1 = 95 patients
District 2 = 92 patients
Randomisation District 1 and District 2
District 1 - MDS-HC(Barthel, MMSE,Lawton
to compare outcomes)
4 patients refuse
District 2 - Geriatric Assessment with Barthel, MMSE, Lawton
2 patients refuse
3 patients died 2 patients died
88 patient completed 1 year of follow-up 88 patient completed 1 year of follow-up
Landi F. et al., JAGS 2001;49:1288-1293
Use of Home Care (1-year of follow-up) in the treated and control groups
Landi F. et al., JAGS 2001;49:1288-1293
ESPERIENZA ESPERIENZA ASL BERGAMOASL BERGAMO
Media indici funzionali (12 mesi)Media indici funzionali (12 mesi)
0 20 40 60
CP
SIA
DL
AD
L
Media giorni di degenza in ospedaleMedia giorni di degenza in ospedale
p vs. trattati < 0.001 p vs. trattati < 0.001 *TrattatiTrattati ControlliControlli
0 10 20 30
*
*
Per
pers
ona
Per
rico
vero
Landi F. et al., JAGS 2001;49:1288-1293
*
*
Time before hospitalisation
4003002001000
1,0
,9
,8
,7
,6
Treated
ControlP=0.05 (log rank test)
Hospitalization during follow-up
Landi F. et al., JAGS 2001;49:1288-1293
0 10 20 30Media giorni di degenza in ospedale
p vs. trattati < 0.001 *Trattati Controlli
*
*
Per
per
sona
Per
ric
over
o
Landi F. et al., J Clin Epidemiol 2001;54:968-70
A new model of integrated home care for the elderly: impact on hospital use.
Landi F., Onder G., Russo A., Tabaccanti S., Rollo R., Federici S., Tua E., Cesari M., Bernabei R
Comprehensive Geriatric Assessment
Patient level
Population level Database
Prognostic factors
Outcome measurements
Quality control indicators
Make the physical exam complete
Better care plan
Comparisons
Developing an evidence-base for community care services in Europe
The Aged Home Care projectADHOC
Monza (I)
Prague(CZ)
Helsinki (FIN)
Amiens (F)
Copenaghen (DK)
Maidstone Ashford(UK)
Amsterdam (NL)
Reykjavik(IS)
Oslo (N)
Stockholm(S)
NurnbergBayreuth(D)
Monza Monza (I)(I)
Prague Prague (CZ)(CZ)
Helsinki Helsinki (FIN)(FIN)
Amiens Amiens (F)(F)
CopenaghCopenaghen (DK)en (DK)
MaidstonMaidstone e AshfordAshford (UK)(UK)
Amsterdam Amsterdam (NL)(NL)
ReykjaviReykjavik (IS)k (IS)
Oslo (N)Oslo (N)
StockholStockholm (S)m (S)
Bielefeld Bielefeld (D)(D)
interRAI
Minimum Data Set for Home Minimum Data Set for Home CareCare- CognitionCognition- Communication/HearingCommunication/Hearing- VisionVision- Mood and BehaviourMood and Behaviour- Social FunctioningSocial Functioning- Informal support servicesInformal support services- Physical functioningPhysical functioning- ContinenceContinence- Disease diagnosesDisease diagnoses- Health statusHealth status- Preventive health measuresPreventive health measures- Nutrition/Hydration statusNutrition/Hydration status- Dental statusDental status- Skin conditionSkin condition- Enviromental AssessmentEnviromental Assessment- Service UtilisationService Utilisation
European Home Care Services European Home Care Services (EUHCS) assessment form(EUHCS) assessment form
Setting:Setting:- Demographic characteristics Demographic characteristics - Hospital and nursing care bedsHospital and nursing care beds
Service structures:Service structures:- Financial structuresFinancial structures- Management structuresManagement structures- Range and organization of services Range and organization of services providedprovided
Service delivery:Service delivery:- Eligibility criteriaEligibility criteria- Referral systemsReferral systems- Provision of integrated serviceProvision of integrated service- Health/social professionals and Health/social professionals and administrative personnel per patientadministrative personnel per patient- Total number of patients per yearTotal number of patients per year- Mean duration of service provision Mean duration of service provision per patientper patient- Days per week of service provisionDays per week of service provision- Night and respite care servicesNight and respite care services- Waiting lists availabilityWaiting lists availability- Use of any validated assessment Use of any validated assessment instrumentsinstruments- Application of any specific Application of any specific guidelineguideline
Death registriesDeath registries
Health Services UseHealth Services Use
- ER- ER
- Hospital and nursing home- Hospital and nursing home
Case ManagerCase Manager
No Case No Case ManagerManager
Log rank < Log rank < 0.0010.001
00 33 66 99 1122
Case Manager e Case Manager e Istituzionalizzazione in Istituzionalizzazione in
RSARSA
On
der
G, L
and
i F. J
AG
S, i
n p
ress
On
der
G, L
and
i F. J
AG
S, i
n p
ress
Relationship between mean MDS HC IADL index and mean MDS ADL hierarchy score by country
Carpenter I et al, Aging Clin Exp Res 2004;16:259-269
Relationship between mean MDS Cognitive Performance Scale and mean MDS ADL hierarchy by country
Carpenter I et al, Aging Clin Exp Res 2004;16:259-269
Proposal of a service delivery integration index of home care for older persons: application in several
European cities
• To propose an integration index of home care delivery to older persons, to study its validity and to apply it to home care services of European cities;
• Data are from the “the Aged in Home care”(AdHoc) study, which includes data on older adults in home care in: Czech Republic, Denmark, UK, Finland, France, Germany, Iceland, Italy, the Netherlands, Norway and Sweden.
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
Integration Index (29 items)• Comprehensive geriatric assessment • Multidisciplinary team approach
• Team meeting for care planning • Case manager
• Participation of GP to team meeting • Day and night service provision
• Weekend provision • Single entry point
• Hospital discharge management
• Decubitus care • Catheter management
• Intra venous medication • Nutritional therapy
• Suctioning
• Therapies (occupational, speech, psycho-social and, physiotherapy)
• Assistance for five instrumental activities of daily living (cooking, shopping, cleaning, laundry, meals on wheels)
• Assistance for three activities of daily living (ADL: feeding, bathing, dressing)
• Assistance for two surveillance items (supervision, tele-help)
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
Score distribution of the integration index among participating cities
0 5 10 15 20 25
Monza
Prague
Copenhagen
Helsinki
Amiens
Reykjavik
Amsterdam
Stockolm
Ashford/Maidstone
Oslo
Nuremberg/Bayreuth
Cit
ies
Total score
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
Factor analysisFactor analysis shows two factors accounting for 51% of total variance:
Factor 1. including working arrangements facilitating integration of services provided (i.e. CGA, case manager, team meeting, multidisciplinary approach);
Factor 2. including mostly items related to social and health care
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
1,000000,00000-1,00000-2,00000
REGR factor score 1 for analysis 2
1,00000
0,00000
-1,00000
-2,00000
RE
GR
fac
tor
sc
ore
2
fo
r an
aly
sis
2
11
10
9
8
7
6
5
4
3
2
1
2
1
3
IT
IS UK
D
CZ
F
NL
DKFI
NO
S
The combination of these two factors shows 3 models of care:The combination of these two factors shows 3 models of care:
1. Extensive social and health care with very little integration of services (Oslo, Stockholm, Helsinki, Copenhagen and Amsterdam);
2. Integration of services and few or no social and health care delivery (Monza, Reykjavik and Ashford/Maidstone).
3. Few social and health care delivery and few or no integration (Amiens and Prague).
Henrard JC, Bernabei R, et al. Int J Integrated Care 2006 in press
L’assistenza all’anziano L’assistenza all’anziano fragile - situazione attualefragile - situazione attuale
OSPEDALE (Azienda)
DIVISIONI PER ACUTI
DISTRETTO
UVG (UOD)
RSA AD (ADI) C.DIURNI
… … in futuroin futuro
AZIENDA OSPEDALE
DIVISIONI PER ACUTI
DIVISIONI POST ACUTI
RSA
DISTRETTO
UVG (UOD)
RSA AD (ADI) C.DIURNI
CASE CASE MANAGERMANAGER +