[Tuscan Chronic Care Model: a preliminary analysis]

the aim of this study is to present a preliminary analysis of efficacy and effectiveness of a model of chronically ill care (Chronic Care Model, CCM).

the analysis took into account 106 territorial modules, 1016 General Practitioners and 1,228,595 patients. The diagnostic and therapeutic pathways activated (PDTA), involved four chronic conditions, selected according to the prevalence and incidence, in Tuscany Region: Diabetes Mellitus (DM), Heart Failure (SC), Chronic Obstructive Pulmonary Disease (COPD) and stroke. Six epidemiological indicators of process and output were selected, in order to measure the model of care performed, before and after its application: adherence to specific follow-up for each pathology (use of clinical and laboratory indicators), annual average of expenditure per/capita/euro for diagnostic tests, in laboratory and instrumental, average expenditure per/capita/year for specialist visits; hospitalization rate for diseases related to the main pathology, hospitalization rate for long-term complications and rate of access to the emergency department (ED). Data were collected through the database; the differences before and after the intervention and between exposed and unexposed, were analyzed by method "Before-After (Controlled and Uncontrolled) Studies". The impact of the intervention was calculated as DD (difference of the differences).

DM management showed an increased adhesion to follow-up (DD: +8.1%), and the use of laboratory diagnostics (DD: +4,9 €/year/pc), less hospitalization for long-term complications and for endocrine related diseases (DD respectively: 5.8/1000 and DD: +1.2/1000), finally a smaller increase of access to PS (DD: -1.6/1000), despite a slight increase of specialistic visits (DD: +0,38 €/year/pc). The management of SC initially showed a rising adherence to follow-up (DD: +2.3%), a decrease of specialist visits (DD:E 1.03 €/year/pc), hospitalization and access to PS for exacerbations (DD: -4.4/1000 and DD: -6.1/100, respectively), compared with a slight increase of diagnostic tests (DD: +2.10 €/year/pc). Stroke showed the following outcomes: increased consumption of instrumental diagnostics and imaging (DD: +1.65 €/year/pc) and growing hospitalizations for related conditions (DD 6.1/1,000). The care of patients with COPD, finally, has produced an increase in overall expenditure on medicines (DD: +39.71/year/pc) associated with the decrease of hospitalization for related conditions (DD: -2.7/1,000).

the Tuscany CCM has proven a promising model of integrated management and taking care for chronic patients, can have a positive impact on the quality of life and on the total health expenditure. Additional monitoring studies are desirable in perspective of expanding the model on all over the national territory.