Prospective cohort study for assessment of integrated care with a triple aim approach: hospital at home as use case

Carme Herranz, Rubèn González-Colom, Erik Baltaxe, Nuria Seijas, Maria Asenjo, Maaike Hoedemakers, David Nicolas, Emmanuel Coloma, Joaquim Fernandez, Emili Vela, Isaac Cano, Maureen Rutten-van Mölken, Josep Roca, Carme Hernandez, Carme Herranz, Rubèn González-Colom, Erik Baltaxe, Nuria Seijas, Maria Asenjo, Maaike Hoedemakers, David Nicolas, Emmanuel Coloma, Joaquim Fernandez, Emili Vela, Isaac Cano, Maureen Rutten-van Mölken, Josep Roca, Carme Hernandez

Abstract

Background: Applicability of comprehensive assessment of integrated care services in real world settings is an unmet need. To this end, a Triple Aim evaluation of Hospital at Home (HaH), as use case, was done. As ancillary aim, we explored use of the approach for monitoring the impact of adoption of integrated care at health system level in Catalonia (Spain).

Methods: Prospective cohort study over one year period, 2017-2018, comparing hospital avoidance (HaH-HA) with conventional hospitalization (UC) using propensity score matching. Participants were after the first episode directly admitted to HaH-HA or the corresponding control group. Triple Aim assessment using multiple criteria decision analysis (MCDA) was done. Moreover, applicability of a Triple Aim approach at health system level was explored using registry data.

Results: HaH-HA depicted lower: i) Emergency Room Department (ER) visits (p < .001), ii) Unplanned re-admissions (p = .012); and iii) costs (p < .001) than UC. The weighted aggregation of the standardized values of each of the eight outcomes, weighted by the opinions of the stakeholder groups considered in the MCDA: i) enjoyment of life; ii) resilience; iii) physical functioning; iv) continuity of care; v) psychological wellbeing; (vi) social relationships & participation; (vii) person-centeredness; and (viii) costs, indicated better performance of HaH-HA than UC (p < .05). Actionable factors for Triple Aim assessment of the health system with a population-health approach were identified.

Conclusions: We confirmed health value generation of HaH-HA. The study identified actionable factors to enhance applicability of Triple Aim assessment at health system level for monitoring the impact of adoption of integrated care.

Registration: ClinicalTrials.gov (26/04/2017; NCT03130283).

Keywords: Chronic care; Health Delivery Assessment; Health Services Research; Hospital at Home; Implementation Science; Multiple Criteria Decision Analysis; Triple Aim.

Conflict of interest statement

All authors have disclosed no conflicts of interest.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Distribution of hospital admissions during the study period. Five-hundred eighty-six first episodes of HaH admissions, directly from the Emergency Room (HaH-HA), were registered during the study period. A sample of 2.631 conventional hospitalizations was used to generate a usual care (UC) group, as described in the text. The entire intervention group, after propensity score matching (PSM), consisted of 441 HaH-HA patients that were compared with the corresponding matched controls (UC), as reported in (Carme H, Carme H, Erik B, Nuria S, Ruben G, Asenjo M, David N, Enric C, Fernandez J, Isaac C, Roca J. Assessment of Hospital Avoidance in a Real-World Setting: a Prospective Cohort Study, Submitted) During the study period, two-hundred consecutive HaH-HA patients were assessed with a Triple Aim approach to perform Multiple Criteria Decision Analysis (MCDA) that was finally done in 137 HaH-HA patients after PSM with a UC group. Comparisons between the entire HaH-HA population (n = 586), the CCA study (n = 441) and the current study (n = 137) are reported in Tables 1S-3S
Fig. 2
Fig. 2
Sensitivity analysis of MCDA with DCE weights based on a Bootstrap analysis (1,000 iterations) of the MCDA overall score between hospital avoidance (HaH-HA) (green) and usual care (UC) (red) groups. In each iteration, the values of the eight outcomes considered in the MCDA were weighted according to the DCE results and subsequently summed to obtain a single overall value score. The panels show the mean overall value score across all bootstrap iterations (set to 1000) and their 95% Uncertainty Intervals (UI) for HaH-HA and UC and for each stakeholder group: A) Patients; B) Carers; C) Professionals; D) Payers + Policy Makers. The four panels show no overlap between intervention and control groups along the bootstrap replications
Fig. 3
Fig. 3
Quality of chronic care in the study areas

References

    1. Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document. Open. 2017;7:13318. doi: 10.1136/bmjopen-2016-013318.
    1. Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Republished research: Implementation research: What it is and how to do it. Br J Sports Med. 2014;48(8):731–6. doi: 10.1136/bmj.f6753.
    1. Struckmann V, Leijten FRM, van Ginneken E, Kraus M, Reiss M, Spranger A, et al. Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review. Health Policy (New York) 2018;122(1):23–35. doi: 10.1016/j.healthpol.2017.08.008.
    1. Low L-F, Fletcher J. Models of home care services for persons with dementia: a narrative review. Int Psychogeriatrics. 2015;27(10):1593–600. doi: 10.1017/S1041610215000137.
    1. World Health Organization. Integrated care models: an overview [Internet]. Health Services Delivery Programme. 2016. Available from:
    1. Kadu M, Ehrenberg N, Stein V, Tsiachristas A. Methodological quality of economic evaluations in integrated care: Evidence from a systematic review. Int J Integr Care. 2019;19(3):1–34. doi: 10.5334/ijic.4675.
    1. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ [Internet]. 2007 Mar 3 [cited 2022 Jul 24];334(7591):455–9. Available from:
    1. Jebraeily M, Amin VALIZADE HASANLOEI M, Rahimi B, Valizade Hasanloei MA. Design of a Management Dashboard for the Intensive Care Unit: Determining Key Performance Indicators and their Required Capabilities. Appl Med Informatics Orig Res. 2019;41(3):111–21.
    1. Lau MK, Bounthavong M, Kay CL, Harvey MA, Christopher MLD. Clinical dashboard development and use for academic detailing in the U.S. Department of Veterans Affairs. J Am Pharm Assoc [Internet]. 2019 Mar 1 [cited 2022 Jul 24];59(2):S96-S103.e3. Available from:
    1. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ [Internet]. 2021 Sep 30 [cited 2022 Jul 24];374. Available from:
    1. Yang H, Dervin G, Madden S, Beaulé PE, Gagné S, Crossan ML, et al. Postoperative home monitoring after joint replacement: Feasibility study. J Med Internet Res. 2018;20(9):e10168.
    1. Looman W, Struckmann V, Köppen J, Baltaxe E, Czypionka T, Huic M, et al. Drivers of successful implementation of integrated care for multi-morbidity: Mechanisms identified in 17 case studies from 8 European countries. Soc Sci Med [Internet]. 2021 May 1 [cited 2022 Apr 4];277:113728. Available from:
    1. Czypionka T, Kraus M, Reiss M, Baltaxe E, Roca J, Ruths S, et al. The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs. Available from: 10.1186/s12913-020-05917-9
    1. European Commission. Jadecare | Joint Action on implementing digitally integrated person-centred care [Internet]. 2022 [cited 2022 Apr 4]. Available from:
    1. Rutten-van Mölken M. Common Challenges Faced in EU-funded Projects on Integrated Care for Vulnerable Persons. 2017; Available from: 10.5334/ijic.3104
    1. Bodenbeimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med. 2014;12(6):573–576. doi: 10.1370/afm.1713.
    1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, And Cost. 101377/hlthaff273759. 2017 Aug 2;27(3):759–69.
    1. Porter ME. Value-based health care delivery. Ann Surg [Internet]. 2008 Oct [cited 2022 Apr 6];248(4):503–9. Available from:
    1. Baltaxe E, Cano I, Herranz C, Barberan-Garcia A, Alonso A. Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols. BMC Heal Serv Res. 2019;19(1):370. doi: 10.1186/s12913-019-4174-2.
    1. Vela E, Tényi Á, Cano I, Monterde D, Cleries M, Garcia-Altes A, et al. Population-based analysis of patients with COPD in Catalonia: A cohort study with implications for clinical management. BMJ Open. 2018;8(3).
    1. Medina A, Schiaffino A. Health Survey of Catalunya. Health status, health-related behaviours and use of health services in Catalunya. Main results ESCA 2017. Executive summary [Internet]. 2018. Available from:
    1. Rutten-Van Mölken M, Leijten F, Hoedemakers M, Tsiachristas A, Verbeek N, Karimi M, et al. Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analysis (MCDA). Available from: 10.1186/s12913-018-3367-4
    1. Leijten FRM, Struckmann V, van Ginneken E, Czypionka T, Kraus M, Reiss M, et al. The SELFIE framework for integrated care for multi-morbidity: Development and description. Health Policy (New York) 2018;122(1):12–22. doi: 10.1016/j.healthpol.2017.06.002.
    1. Tsiachristas A, Cramm JM, Nieboer A, Rutten-Van Mölken M. Broader economic evaluation of disease management programs using multi-criteria decision analysis. Int J Technol Assess Health Care [Internet]. 2013 Jul [cited 2022 Apr 4];29(3):301–8. Available from:
    1. Leff B. Defining and disseminating the hospital-at-home model Key points. CMAJ. 2009;180(2):156–7. doi: 10.1503/cmaj.081891.
    1. Shepperd S, Iliffe S, Doll HA, Clarke MJ, Kalra L, Wilson AD, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev [Internet]. 2016 Sep 1 [cited 2022 Apr 4];2016(9). Available from: /pmc/articles/PMC6457791/
    1. Gonçalves-Bradley DC, Iliffe S, Doll HA, Broad J, Gladman J, Langhorne P, et al. Early discharge hospital at home. Cochrane Database Syst Rev [Internet]. 2017 Jun 26 [cited 2022 Apr 4];2017(6). Available from: /pmc/articles/PMC6481686/
    1. Hernández C, Aibar J, Seijas N, Puig I, Alonso A, Garcia-Aymerich J, et al. Implementation of home hospitalization and early discharge as an integrated care service: A ten years pragmatic assessment. Int J Integr Care [Internet]. 2018 Apr 1 [cited 2022 Apr 19];18(2). Available from:
    1. Hernández C, Alonso A, Garcia-Aymerich J, Grimsmo A, Vontetsianos T, García Cuyàs F, et al. Integrated care services: lessons learned from the deployment of the NEXES project. Int J Integr Care. 2015;15:e006.
    1. Salut S C. Model organitzatiu d’hospitalització a domicili de Catalunya. CatSalut Serv Català la Salut [Internet]. Available from:
    1. Mas M, Santaeugènia SJ, Tarazona-Santabalbina FJ, Gámez S, Inzitari M. Effectiveness of a Hospital-at-Home Integrated Care Program as Alternative Resource for Medical Crises Care in Older Adults With Complex Chronic Conditions. J Am Med Dir Assoc [Internet]. 2018 Oct 1 [cited 2022 Jul 24];19(10):860–3. Available from:
    1. Mas M, Inzitari M, Sabaté S, Santaeugènia SJ, Miralles R. Hospital-at-home Integrated Care Programme for the management of disabling health crises in older patients: comparison with bed-based Intermediate Care. Age Ageing [Internet]. 2017 Nov 1 [cited 2022 Jul 22];46(6):925–31. Available from:
    1. Ribbink ME, Gual N, MacNeil-Vroomen JL, Ars Ricart J, Buurman BM, Inzitari M, et al. Two European Examples of Acute Geriatric Units Located Outside of a General Hospital for Older Adults With Exacerbated Chronic Conditions. J Am Med Dir Assoc [Internet]. 2021 Jun 1 [cited 2022 Jul 24];22(6):1228–34. Available from:
    1. Colprim D, Martin R, Parer M, Prieto J, Espinosa L, Inzitari M. Direct admission to intermediate care for older adults with reactivated chronic diseases as an alternative to conventional hospitalization. J Am Med Dir Assoc [Internet]. 2013 [cited 2022 Jul 24];14(4):300–2. Available from:
    1. Epping-Jordan J, Pruitt S, Bengoa R, Wagner E. Improving the quality of health care for chronic conditions. Qual Saf Health Care [Internet]. 2004 Aug 1 [cited 2022 Apr 6];13(4):299–305. Available from:
    1. Government of Catalonia M of H. Health Plan for Catalonia 2011–2015. 2012; Available from:
    1. Generalitat de Catalunya, Departament de Salut. Pla de Salut de Catalunya 2016–2020. Dir Gen Planif en Salut [Internet]. 2016;162. Available from:
    1. Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. Available from:
    1. Tsiachristas A, Ellis G, Buchanan S, Langhorne P, Stott DJ, Shepperd S. Should I stay or should I go? A retrospective propensity score-matched analysis using administrative data of hospital-at-home for older people in Scotland. BMJ Open [Internet]. 2019 May 1 [cited 2022 Apr 4];9(5):23350. Available from: /pmc/articles/PMC6527981/
    1. Diamond A, Sekhon JS. Genetic Matching for Estimating Causal Effects: A General Multivariate Matching Method for Achieving Balance in Observational Studies. Rev Econ Stat [Internet]. 2013 Jul 1 [cited 2022 Apr 4];95(3):932–45. Available from:
    1. Monterde D, Vela E, Clèries M, Garcia-Eroles L, Roca J, Pérez-Sust P. Multimorbidity as a predictor of health service utilization in primary care: a registry-based study of the Catalan population. Available from: 10.1186/s12875-020-01104-1
    1. Fetter RB, Shin Y, Freeman JL, Averill RF, Thompson JD. Case mix definition by diagnosis-related groups. Med Care. 1980;18(Suppl 2):1–53.
    1. Mahalanobis Distance. In: The Concise Encyclopedia of Statistics [Internet]. New York, NY: Springer New York; 2008. p. 325–6. Available from: 10.1007/978-0-387-32833-1_240
    1. Rubin DB. Using propensity scores to help design observational studies: Application to the tobacco litigation. Matched Sampl Causal Eff. 2006;365–82.
    1. Coast J, Peters TJ, Natarajan L, Sproston K, Flynn T. An assessment of the construct validity of the descriptive system for the ICECAP capability measure for older people. Qual Life Res. 2008;17(7):967–976. doi: 10.1007/s11136-008-9372-z.
    1. Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: Assessing the ability to bounce back. Int J Behav Med. 2008;15(3):194–200. doi: 10.1080/10705500802222972.
    1. Jenkinson C, Coulter A, Wright L. Short form 36 (SF 36) health survey questionnaire: Normative data for adults of working age. Br Med J [Internet]. 1993;306(6890):1437–40. Available from:
    1. Uijen AA, Schellevis FG, van den Bosch WJHM, Mokkink HGA, van Weel C, Schers HJ. Nijmegen Continuity Questionnaire: Development and testing of a questionnaire that measures continuity of care. J Clin Epidemiol. 2011;64(12):1391–1399. doi: 10.1016/j.jclinepi.2011.03.006.
    1. Berwick DM, Murphy JM, Goldman PA, Ware JE, Barsky AJ, Weinstein MC. Performance of a five-item mental health screening test. Med Care. 1991;29(2):169–176. doi: 10.1097/00005650-199102000-00008.
    1. Cardol M, de Haan RJ, van den Bos GAM, de Jong BA, de Groot IJM. The development of a handicap assessment questionnaire: the Impact on Participation and Autonomy (IPA) Clin Rehabil. 1999;13(5):411–419. doi: 10.1191/026921599668601325.
    1. Lloyd H, Fosh B, Whalley B, Byng R, Close J. Validation of the person-centred coordinated care experience questionnaire (P3CEQ) Int J Qual Heal Care. 2019;31(7):506–512. doi: 10.1093/intqhc/mzy212.
    1. Rutten-Van Mölken M, Karimi M, Leijten F, Hoedemakers M, Looman W, Islam K, et al. Comparing patients’ and other stakeholders’ preferences for outcomes of integrated care for multimorbidity: a discrete choice experiment in eight European countries. BMJ Open. 2020;10:37547. doi: 10.1136/bmjopen-2020-037547.
    1. Breslow NE, Day NE. Statistical methods in cancer research. Volume II--The design and analysis of cohort studies. IARC Sci Publ. 1987;(82):1–406.
    1. Zeileis A. R: The R Project for Statistical Computing [Internet]. 2022 [cited 2022 Apr 4]. Available from:
    1. Hernández C, Aibar J, Seijas N, Puig I, Alonso A, Garcia-Aymerich J, et al. Implementation of home hospitalization and early discharge as an integrated care service: A ten years pragmatic assessment. Int J Integr Care. 2018;18(2):12. doi: 10.5334/ijic.3431.
    1. Schwartz AR, Cohen-Zion M, Pham L V., Gal A, Sowho M, Sgambati FP, et al. Brief digital sleep questionnaire powered by machine learning prediction models identifies common sleep disorders. Sleep Med [Internet]. 2020 Jul 1 [cited 2022 Apr 6];71:66–76. Available from:
    1. Barberan-Garcia A, Cano I, Bongers BC, Seyfried S, Ganslandt T, Herrle F, et al. Digital Support to Multimodal Community-Based Prehabilitation: Looking for Optimization of Health Value Generation. Vol. 11, Frontiers in Oncology. 2021.
    1. Home - Selfie 2020 - [Internet]. [cited 2018 Mar 7]. Available from:

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