The majority of approaches tend to focus on populations with defined conditions

The most frequently targeted conditions were type 2 diabetes, asthma/chronic obstructive pulmonary disease (COPD), cardiovascular diseases (chronic heart failure, ischaemic heart disease, stroke), cancer, and mental health problems. These conditions are typically targeted by means of structured disease management to enhance coordination, which are implemented at the national level, or, in decentralized systems, at regional level. There is wide variation in the nature and scope of approaches and the extent to which nonmedical staff is involved in care delivery. Commonly, the general practitioner (GP) or family physician tends to act as principal provider or ‘care coordinator’.

There is a trend towards strengthening the role of nurses in care delivery and coordination

The use of nurses in care delivery and coordination is common in systems that have a tradition in multidisciplinary team working (Nolte & McKee, 2008a). Examples include nurse-led clinics and nurse-led case management as established in countries such as England, Italy and the Netherlands. Conversely, the introduction of nurse-led approaches in primary care has remained challenging in systems where primary care is traditionally provided by doctors in solo practice with few support staff. However, there are moves in these countries towards enhanced functions of nurses in care coordination or case management, as for example in Denmark, France and Lithuania. Countries are also seeking to strengthen the role of nurses in providing patient self-management support or the delivery of selected medical tasks, although most often such tasks have remained under the supervision of the GP or family physician, such as in Austria, France and Germany.

Approaches that seek to reduce barriers between sectors remain less common

Many of the observed approaches seeking to enhance the care for people with chronic or long-term conditions tend to be implemented within existing organizational and governance structures without necessarily overcoming existing structural or sectoral boundaries. Such approaches may still be effective in enhancing coordination, through for example, the use of structured referral pathways, but structural barriers between sectors remain, potentially impeding further progress in advancing service delivery towards those better suited to meet complex chronic care needs.

Approaches that seek to more specifically reduce or eliminate these structural or sectoral barriers were less common. Typically, such approaches would focus on managing the primary-secondary care or the secondary care-rehabilitation interface. Examples include some provider networks in France, a range of integrated care contracts in Germany, or the Stroke service Delft in the Netherlands as one specific example of an integrated care service. Frequently, although not always, approaches that perhaps challenge the established ways to service delivery by overcoming sectoral boundaries through for example new ways of contracting between funders and providers were implemented as pilot projects, with the integrated care pilots and the Partnership for Older People Projects (POPP), both in England, or the Improving intersectoral collaboration pilot in Lithuania as examples. The “SIKS” (Integrated effort for people living with chronic diseases) project in Copenhagen, Denmark, provides an illustration of an integrated care ‘pilot’ that ended following completion of the project phase but that crucially informed policy development for coordinated care approaches across Denmark more widely.

The implementation of approaches frequently involves financial incentives

In a number of countries, the introduction of new approaches to enhance the care for people with chronic conditions involved additional funding in the form of start-up funding to support infrastructural development (for example, administrative structures). These can be targeted at payers, for example, municipalities in Denmark, integrated care pilots in England, or integrated care contracts in Germany, or, in some cases, support providers, such as in the case of provider networks in France.

Typically, however, new approaches would involve some form of financial incentive, most frequently targeting individual providers or physicians, such as within disease management programmes (DMPs) in Austria and Germany, GPs (diabetes care) in Denmark, provider networks in France, care groups in the Netherlands and Italy or GP practices in the United Kingdom. Incentives for patients are also being used, but these are less common.

Levels of patient and clinician support vary

Patient access is typically granted in line with access to usual care. Many approaches are being implemented in selected geographical regions and may so potentially limit access to defined population groups. The majority of approaches provide some form of patient self-management support, although the level and scope of support offered varies. The use of clinical information systems for chronic disease management tends to be the least developed strategy in most approaches.

Conceptualizing chronic disease and chronic disease management

Chronic conditions or chronic health problems have been described in different ways (Nolte & McKee, 2008a). We adopted a general definition, which is principally based on the effects and associated care needs, rather than the cause of the condition in question (Unwin, Epping Jordan & Bonita, 2004). We distinguished acute conditions, which are potentially curable within short period, from chronic conditions, which are incurable or require prolonged treatment and care and for which there is a chance of developing intercurrent episodes or acute illnesses associated with the chronic condition (Holman & Lorig, 2000).

We restricted the scope of approaches reported in this book to the management of people with established chronic health problems although we also considered measures of secondary prevention targeted at people at high risk of developing a chronic disabling disease, such as vascular risk management. However, we excluded measures of primary prevention or health promotion in the context of this work.

Although the DISMEVAL project focused, in its core, on approaches that can be broadly subsumed under the heading of ‘disease management’, we recognize that definitions of this concept vary widely (Krumholz et al., 2006; Nolte & McKee, 2008b), and we discuss this issue in detail in Volume 1 (Nolte, Knai & Saltman, 2014). In the present volume, we defined disease management as comprising the following components: (a) an integrated approach to care or coordination of care among providers, including physicians, hospitals, laboratories and pharmacies; (b) patient education; and (c) monitoring or collection of patient outcomes data for the early detection of potential complications (Krumholz et al., 2006).

Selection of countries

As many countries in Europe are in the process of experimenting with or implementing various approaches to chronic care, the selection of countries for detailed review was of necessity pragmatic. Country selection was guided by three main criteria in order to capture (1) the range of approaches to funding and governing health care across Europe; (2) the range of stages of economic development; and (3) geographical spread across the European Union (EU).

On this basis, we selected 12 countries for review: Austria, Denmark, England, Estonia, France, Germany, Hungary, Italy, Latvia, Lithuania, the Netherlands and Switzerland (the only non-EU country). Five of these countries (Denmark, England, France, Germany and the Netherlands) were reviewed in previous work (Nolte, McKee & Knai, 2008). However, renewed inclusion was justified as all have developed existing approaches further or have implemented new approaches and can so provide important insights into the factors that have made these developments possible (or indeed hindered further advancement).

All of the countries reviewed in this book have a similar commitment to providing universal and reasonably equitable access to health care for their populations, but do so in different ways. Four countries (Denmark, England, Italy and Latvia) operate primarily tax funded systems, while the health systems in Austria, Estonia, France, Germany, Hungary, Lithuania and the Netherlands are primarily funded through statutory social health insurance. Switzerland operates a mandatory private insurance system (Table 1.1).

Table 1.1

Principles of health care financing in twelve countries in Europe.

Survey of approaches to chronic disease management

We developed a common template for the collection of data on approaches to chronic disease management in European systems. The development of the template was based on a structured questionnaire used in the framework of a previous study (Nolte, Knai & McKee, 2008) and informed, to a great degree, by the Chronic Care Model (CCM) developed by Wagner and colleagues in the United States (Wagner, 1998). The CCM comprises four interacting components that are considered key to providing high-quality care for those with chronic health problems: self-management support, delivery system design, decision support and clinical information systems. These are set within a health system context that links an appropriately organized delivery system with complementary community resources and policies.

Accordingly, the template sought to gather information on (i) the health system and policy context and (ii) the type and format of approaches to managing chronic disease, examining nature and scope of the four components identified by the CCM as crucial to effective chronic care. The template was amended further to include a third section on the evaluation of existing approaches and a final section exploring system markers of success or failure for organizational approaches to chronic disease management, including an analysis of the strengths, weaknesses, opportunities and threats of the current system context and the critical success factors for chronic disease management in the country under review. The template used simple checkboxes as well as open-ended questions. Where appropriate and relevant, sections included a glossary of definitions of terms, for example, of approaches to chronic disease management, and guidance for completion, including examples and checklists. A draft template was circulated among partners of the DISMEVAL project to ensure that definitions appropriately reflect different health systems contexts and the overall applicability of the instrument.

Data collection using the finalized template was undertaken by key informants in the countries under review. Of the 12 countries considered for review, six were represented by DISMEVAL project partners (Austria, Denmark, England, France, Germany and the Netherlands) who were invited to complete the template. For countries not represented in DISMEVAL, key informants were identified through existing professional networks of the lead editors, based on an established network of country experts in eight European countries (the International Healthcare Comparisons Network) (Nolte et al., 2008). Key informants thus identified had to demonstrate expertise in the area of chronic disease or an understanding of the health policy and system context of the country in question as shown by relevant publications in the academic literature or roles in relevant governmental advisory bodies.

Project partners and key informants were asked to adopt an evidence-based approach by making use of the best available data, using all relevant sources including ongoing or completed research projects, policy documents and routine statistics, surveys and census data related to chronic disease. They were further asked to compile data in consultation with organizations involved in the management of chronic disease such as central government departments, health authorities (or their equivalent), arm’s-length bodies or subordinate agencies and academic and training organizations. Where appropriate and necessary, additional information was to be gathered through interviews with key stakeholders and reviews of work in progress such as pilot projects, green or white papers, consultation documents, committee reports, parliamentary hearings and proposals.

A number of countries were characterized by a wide range of frequently small-scale approaches at the local or regional level, in some cases conceptualized as pilot studies intended for subsequent rollout to larger geographical areas (examples include Austria, Denmark, Italy and Switzerland). As it was beyond the scope of this study to provide a comprehensive inventory of all approaches being implemented in a given country, key informants were asked to present a “sample” of approaches considered representative of a given health system in terms of the type and setting of delivery model, providers involved, key strategies employed and the population covered.

Principal data collection was carried out from June 2009 to December 2009. Each completed template formed the basis for a country report with a follow-up to complete missing information and clarify data. Draft country reports were reviewed by the key informant leading template completion for each country in 2011 and again in early 2014 to ensure accuracy and allow for the update of information where necessary and appropriate. Country reports formed the basis of the systematic cross-country comparison presented in Volume I.