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In 2009, China strengthened its public health service system. Since then, the country has made remarkable achievements in community-based chronic disease prevention and control; however, certain groups still have unmet needs. During 2019 to 2029, China will consolidate the top-level design of its medical health system. During this period, the coordination of department policies, improvement of service delivery mechanisms, building an integrated health service system, and other issues will be highlighted. This study will provide a basis for designing China's chronic disease prevention and control system during the next stage of development. We will consider the unmet needs of patients with chronic diseases as an indicator for remodeling the prediction system in combination with the elements and structural theories of complex health systems. In this article, we first introduce the definition and measurement methods of unmet needs. Second, we identify the existing unmet needs found among patients with chronic diseases with reference to the chronic disease prevention and control policies of China as well as current service items. Finally, we propose the design of community chronic disease service package for the next development stage based on unmet needs of patients with chronic diseases. We also provide suggestions for how to improve China's chronic care delivery system.

Introduction Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat. Study description This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map. Results The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care. Conclusion The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration.

Over the past decades, pro-growth policies in China led to rapid economic development but overlooked the provision of health care services. Recently, increasing attention is paid to the emergence of integrated delivery systems (IDS) in China, which is envisioned to consolidate regional health care resources more effectively by facilitating patient referral among hospitals. IDS at an inter-city scale is particularly interesting because it involves both the local governments and the hospitals. Incentives among them will affect the development of an inter-city IDS. This paper thereby builds an economic model to examine both the inter-local government and inter-hospital incentives when participating in an inter-city IDS in China. The findings suggest that while inter-hospital incentives matter, inter-local government incentives should also be considered because the missing incentives at the local government level may oppose the development of inter-city IDSs.

Background Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage. Methods A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage. Results Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient’s lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services. Conclusion Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services. Electronic supplementary material The online version of this article (10.1186/s12913-019-3913-8) contains supplementary material, which is available to authorized users.

Background Overactive bladder (OAB) is common and morbid. Medication and diagnosis claims may be specific, but lack sensitivity to identify patients with overactive bladder. We used an “electronic health record (EHR) phenotype” to identify cases and describe treatment choices and anticholinergic burden for OAB. Methods We conducted a retrospective cohort study in a large, integrated health delivery system between July 2011 and June 2012 (2-year follow-up). We examined care from primary care and specialty clinics, medication and procedure use, and anticholinergic burden for each patient. Results There were 7362 patients with an EHR OAB phenotype; 50% of patients were > 65 years old, 74% were female, and 83% were white. The distribution of care included primary care physician (PCP)/specialty co-management (25% of patients); PCP care only (18%); urology only (13%); or some other combination of specialty care (33%). Only 40% of patients were prescribed at least 1 OAB medication during the study. The mean duration of prescribed medication was 1.5 months (95% confidence interval [CI], 1.4 to 1.6 months; range, P Conclusions Although OAB is common and morbid, in a longitudinal study using an EHR OAB phenotype 40% of patients were treated with OAB medication and only briefly.

The Italian Health Ministry recently approved a national plan for tackling chronic care, which sets out the prevailing organisational models and the clinical governance guide lines for major conditions. On the top of these addresses, the plan identified the Population Health Management (PHM) approach as a road map for Regional Healthcare Services (RHS) and organizations. The PHM identifies five pillars: 1) demand analysis, segmentation and targeting; 2) set up of clinical pathways from early prevention to treatment and follow up; 3) identify models of care for chronic care management; 4) personalized care pathways; 5) Results, outcome evaluation and quality improvement.The paper aims to provide a national overview of the PHM development in different RHSs, starting from the five pillars as the key variables for analyzing regional patterns further reinforced by the institutional context analysis of reforms driven by the PHM attainments. For instance, the call for population-based system has accelerated yet the processes of merges and establishment of bigger LHAs as healthcare services commissioners serving population of almost 1 billion inhabitants, on average; yet the processes for centralizing the support management processes and programme planning within the regional governance. The paper analyses in depth five regional cases that firstly underwent the PHM model, detangling the policy and management strategies developed compared to the five pillars as well as the resources, tools, infrastructure and ICT technologies put in place and the models of care. The analysis provides insights from the lessons learnt by these RHSs and the challenges they are facing today, in order to understand the implementation matters with the national endowment of the PHM.

Introduction: Interventions aimed at integrating care have become widespread in healthcare; however, there is significant variability in their success. Differences in organizational contexts and associated capabilities may be responsible for some of this variability. This study develops and validates a conceptual framework of organizational capabilities for integrating care, identifies which of these capabilities may be most important, and explores the mechanisms by which they influence integrated care efforts.Theory/Methods: The Context and Capabilities for Integrating Care (CCIC) Framework was developed through a literature review, and revised and validated through interviews with leaders and care providers engaged in integrated care networks in Ontario, Canada. Interviews involved open-ended questions and graphic elicitation. Quantitative content analysis was used to summarize the data.Results: The CCIC Framework consists of eighteen organizational factors in three categories: Basic Structures, People and Values, and Key Processes. The three most important capabilities shaping the capacity of organizations to implement integrated care interventions include Leadership Approach, Clinician Engagement and Leadership, and Readiness for Change. The majority of hypothesized relationships among organizational capabilities involved Readiness for Change and Partnering, emphasizing the complexity, interrelatedness and importance of these two factors to integrated care efforts.Discussion: The quantitative content analysis of participant interviews suggests that the social and psychological context for integrating care should not be neglected in research and practice. Five of the nine organizational capabilities deemed most important to integrating care are from the “People and Values” domain of the framework. An understanding of the subjective context, and associated organizational capabilities such as leadership approach, clinician engagement, organizational culture, and readiness for change, may be of equal, if not greater, importance to study as the objective contextual factors such as physical features, resources, and organizational/network design. Organizational leaders can use the framework to determine readiness to integrate care, develop targeted change management strategies, and select appropriate partners with overlapping or complementary profiles on key capabilities.Conclusions: We developed a consolidated research- and practice-informed framework to guide the implementation of integrated care interventions and to help focus measurement of organizational context and capabilities. We also prioritized the most important organizational capabilities and explored their inter-relationships via interviews with key informants.Lessons Learned: Participants’ views and experiences did not always align with the initial framework’s structure and wording. Based on the results, we made modifications to terminology. Participants also identified complex, often non-linear relationships among capabilities that require additional study in future research.Limitations: The validation results presented are based on a sample of 29 participants in one Canadian province. Although participants came from diverse organizations and differed in approaches to integrating care, the limited scope of the sample indicates that the results may not be widely generalizable.Suggestions for Future Research: Additional research is needed to empirically test the proposed framework, with a focus on the hypothesized relationships. Research needs to move beyond general statements about variations in the performance of integrated care interventions being due, for example, to “culture” or “leadership”, to more specific assessments of these capabilities.

Background: The US Department of Veterans Affairs (VA) has developed various health information technology (HIT) resources to provide accessible veteran-centered health care. Currently, the VA is undergoing a major reorganization of VA HIT to develop a fully integrated system to meet consumer needs. Although extensive system documentation exists for various VA HIT systems, a more centralized and integrated perspective with clear documentation is needed in order to support effective analysis, strategy, planning, and use. Such a tool would enable a novel view of what is currently available and support identifying and effectively capturing the consumer’s vision for the future. Objective: The objective of this study was to develop the VA HIT Systems Matrix, a novel tool designed to describe the existing VA HIT system and identify consumers’ vision for the future of an integrated VA HIT system. Methods: This study utilized an expert panel and veteran informant focus groups with self-administered surveys. The study employed participatory research methods to define the current system and understand how stakeholders and veterans envision the future of VA HIT and interface design (eg, look, feel, and function). Directed content analysis was used to analyze focus group data. Results: The HIT Systems Matrix was developed with input from 47 veterans, an informal caregiver, and an expert panel to provide a descriptive inventory of existing and emerging VA HIT in four worksheets: (1) access and function, (2) benefits and barriers, (3) system preferences, and (4) tasks. Within each worksheet is a two-axis inventory. The VA’s existing and emerging HIT platforms (eg, My HealtheVet, Mobile Health, VetLink Kiosks, Telehealth), My HealtheVet features (eg, Blue Button, secure messaging, appointment reminders, prescription refill, vet library, spotlight, vitals tracker), and non-VA platforms (eg, phone/mobile phone, texting, non-VA mobile apps, non-VA mobile electronic devices, non-VA websites) are organized by row. Columns are titled with thematic and functional domains (eg, access, function, benefits, barriers, authentication, delegation, user tasks). Cells for each sheet include descriptions and details that reflect factors relevant to domains and the topic of each worksheet. Conclusions: This study provides documentation of the current VA HIT system and efforts for consumers’ vision of an integrated system redesign. The HIT Systems Matrix provides a consumer preference blueprint to inform the current VA HIT system and the vision for future development to integrate electronic resources within VA and beyond with non-VA resources. The data presented in the HIT Systems Matrix are relevant for VA administrators and developers as well as other large health care organizations seeking to document and organize their consumer-facing HIT resources. [J Med Internet Res 2016;18(10):e266]

Times are changing. Taiwan is one of the richest countries in the Asia Pacific region. It enacted its single-payer national health insurance program in 1995: in all estimates, it has been very successful. It has a strong healthcare system and the universal health insurance ensures that all citizens have grown to expect a high level of care. Healthcare systems are designed to meet the healthcare needs of target populations. There are a wide variety of healthcare systems around the world. In some countries, healthcare system planning is distributed among market participants, whereas in others planning is made more centrally among governments, trade unions, charities, religions, or other co-ordinated bodies to deliver planned healthcare services targeted to the populations they serve. However, healthcare planning has often been evolutionary rather than revolutionary. In healthcare all work carried out must be at the highest quality, and a much higher proportion of resources must be invested in quality in healthcare. The aim of this report is to give an overview of the healthcare service provision in Taiwan.

ObjectiveTo determine the prevalence of obesity and its related comorbidities among patients being actively managed at a US academic medical centre, and to examine the frequency of a formal diagnosis of obesity, via International Classification of Diseases, Ninth Revision (ICD-9) documentation among patients with body mass index (BMI) ≥30 kg/m2.DesignThe electronic health record system at Cleveland Clinic was used to create a cross-sectional summary of actively managed patients meeting minimum primary care physician visit frequency requirements. Eligible patients were stratified by BMI categories, based on most recent weight and median of all recorded heights obtained on or before the index date of 1July 2015. Relationships between patient characteristics and BMI categories were tested.SettingA large US integrated health system.ResultsA total of 324 199 active patients with a recorded BMI were identified. There were 121 287 (37.4%) patients found to be overweight (BMI ≥25 and 30 (n=134 488), only 48% (64 056) had documentation of an obesity ICD-9 code. In those patients with a BMI >40, only 75% had an obesity ICD-9 code.ConclusionsThis cross-sectional summary from a large US integrated health system found that three out of every four patients had overweight or obesity based on BMI. Patients within higher BMI categories had a higher prevalence of comorbidities. Less than half of patients who were identified as having obesity according to BMI received a formal diagnosis via ICD-9 documentation. The disease of obesity is very prevalent yet underdiagnosed in our clinics. The under diagnosing of obesity may serve as an important barrier to treatment initiation.

Purpose Identify standard self-report questions about functioning suitable for measuring disability across integrated health and social services. Theory Functional activities can be validly grouped according to the International Classification of Functioning, Disability and Health (ICF) chapters of mobility, self-care, and domestic life. Methods Cross-sectional analysis using information on 112,601 persons interviewed as part of the United States National Health Interview Survey on Disability. We combined related sets of questions and tested the appropriateness of their groupings through confirmatory factor analyses. Construct validity was addressed by seeking to confirm clinically logical relationships between the resulting functional scales and related health concepts, including number of physician contacts, number of bed days, perception of illness, and perception of disability. Results Internal consistency for the summed scales ranged from 0.78 to 0.92. Correlations between the functional scales and related concepts ranged from 0.12 to 0.52 in directions consistent with expectations. Conclusions Analyses supported the 3 ICF chapters. Discussions The routine collection of this core set of functions could enhance decision-making at the client, professional, organizational, and policy levels encouraging cooperation among the medical and social service sectors when caring for people with disabilities.