Managing chronic conditions: lessons learned from a comparative evaluation of chronic care programs in Italy

Abstract

Background: Chronic diseases in western countries represent the 80-85% of costs in the health system and cause about the 86% of deaths[1]. This led to an increase of production of policies focused on management of chronic conditions, both in the national and regional contexts. As an example, in 2016 the Italian Ministry of Health diffused a National Plan for Chronic Diseases, which every region started to apply, through different programs and projects. Objective: The study aims at comparing different policies for chronic diseases, to identify which are the variables bringing to the success or failure of related programs and projects, through the elaboration of a theory driven framework. The scope of the analysis is delimited to ten regions, selected according to three specific conditions: first, presence of active policies on chronic diseases dedicated to the improvement of patient care through a better coordination of care among several settings and the integration of professionals. Therefore, only regions that both deliberated policies and had already implemented related programs or projects were selected. Second, to give a comprehensive representation of the Italian country the study includes regions following a homogeneous distribution on the whole territory. Methodology: In order to conduct the research, the study implements a mixed method based on desk research and interviews. The desk research was conducted through the analysis of scientific literature and available normative sources in a time frame of five years (2014-2018). Semi-structured interviews where then conducted with every region’s responsible for Primary Care, with the aim of validate and integrate the desk research, discuss some projects and explore further policies developments. We then elaborated a framework of evaluation, adapting the theory-driven evaluation framework from H. T. Chen[2] to evaluate the implementation of ten selected programs at a regional level. The framework was discussed by a panel of experts during a Consensus Conference, who were asked to vote and validate the application of the framework to selected programs. The panel consisted of high-level representatives from the following Italian scientific society, patient association and stakeholders: National Association of Hospital Cardiologists (ANMCO), Italian Association of People with Heart Failure (AISC), National Institute of Health (ISS), National Agency for Regional Health Services (Agenas), Italian Federation of Hospitals and Hospital Trusts (FIASO) and one representative for each region. Conclusions: First, we noticed that during the years, programs have been directly implemented in the area of interest, overtaking the experimentation phase which was historically always implemented. Second, we saw that diabetes is the chronic disease on which most programs are focused on. Only after working on diabetes, programs are implemented also on other chronic diseases like hearth failure. Third, the study shows a relevant lack of evaluations on programs after they have been implemented. Finally, programs are increasingly focusing on the patient with all his comorbidities and not only on a single disease. References: 1- CES, The double expansion of morbidity hypothesis: evidence from Italy, 2017. 2- Chen, Practical program evaluation: Assess and improve program planning, implementation, and effectiveness , 2005.

Keywords

• chronic care
• framework
• policy evaluation
• Italy
• regions