Patient-reported measures for integrated care assessment: interprofessional collaboration, self-care and outcomes.
Authors: Pennucci Francesca 
Published: January 2024

Chronicity is spreading and rapidly becoming a urgent issue also for the complexity of care. 32.2 million of NCD deaths (80%) are due to chronic diseases (1). Every country has been developing strategies to guarantee assistance to chronic patients while ensuring the sustainability of the system. Interprofessional collaboration is among the features to improve the assistance for chronic patients and to reach coordination, appropriateness, and continuity along the care pathways (2,3). Data collection on this topic is still scarce, especially from the point of view of patients themselves. Patient Reported Outcome and Experience Measures (PROMs and PREMs) collected in an integrated way can help in understanding the relationship of experience and outcome along the patient care pathway, thus providing a complete vision of the quality and integration of care from the patient perspective (4).
This work aims at reporting some preliminary results about the impact of interprofessional collaboration on the health outcomes and self-care capacity of chronic heart failure (CHF) patients.
Data from the Observatory on PROMs and PREMs of the Tuscany Region in Italy will be used to explore the hypothesis that interprofessional collaboration can lead to better self-care and outcome scores as reported by patients. The selected sample replied to four questionnaires: one at discharge by the hospital, a first follow-up after 30 days; a second follow-up after 7 months; a final follow-up after 12 months (5). Average scores and deltas for the KCCQ-12 and the SCHFI scales will be used to detect potential differences between patients’ self-care, health status and quality of care according to the reported level of integration between the general practitioner and the specialist.
132 responses were valid to be analysed. At baseline, 23% of patients declared that their GP and their specialist were in contact to take care of the care pathway, 15% declared they did not know. Differences between scores are not significant for the KCCQ-12 on health status and quality of life. A weak difference emerged for the Self-care Maintenance about daily lifestyle adherence.
Further research should be conducted on this topic to understand if these results are linked to a scarce knowledge of patients with respect to the joint work of GPs and specialists or if the interprofessional collaboration is not sufficient to guarantee an improvement of outcomes, at least for CHF patients. Indeed, the same analyses could be repeated on other two chronic populations (e.g. diabetic and IBD patients) which are providing their data that will be available next year.

1.2018. “NCD Countdown 2030: Worldwide Trends in NCD Mortality and Progress towards Sustainable Development Goal Target 3.4.” Lancet
2.Pascucci2021. “Impact of Interprofessional Collaboration on Chronic Disease Management.” Health Policy
3.Davidson2022. “What Do Patients Experience? Interprofessional Collaborative Practice for Chronic Conditions in Primary Care” BMC Primary Care
4.Pennucci“Can the Jointly Collection of PROMs and PREMs Improve Integrated Care?” IJIC
5.Pennucci“Piloting a Web-Based Systematic Collection and Reporting of PROMs/PREMs in Chronic Heart Failure.” BMJ Open