In 1998, Edward Wagner, then Director of the MacColl Institute for Healthcare Innovation, developed a model for patients with chronic diseases4 (Fig. 1). Broadly speaking, the model suggested the need to transform the health system to focus on improving the health of the population through a shared vision. This called for the health system and community resources, organizations and institutions to work together to prevent and manage chronic diseases. From a care point of view, it established the need to move toward proactive care models centered on a holistic view of the patient, with an integrated, coordinated and multidisciplinary approach. The CCM also proposed involving both patient and caregiver in disease management and care strategies as a means of strengthening their motivation, knowledge and self-care skills through structured healthcare education and psychosocial activities. The use of decision aids and professional training is encouraged in order to improve health outcomes. Finally, CCM considers the use of information systems as a support for clinical and population management.

Fig. 1.

Conceptual model for the care of patients with chronic diseases (chronic care model) proposed by Wagner.4

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Considerable experience has been accumulated in the last decade in the use of the CCM, showing improvements in quality of care and in the primary clinical outcomes of various chronic diseases.5 These findings are consistent in different countries with different healthcare systems and approaches. Although simple interventions may be attractive, most studies show that the best outcomes are obtained when different elements of the CCM are implemented simultaneously. Despite this evidence, further information is required on the efficiency and economic implications of changes in the organization and functioning of ambulatory care. Most studies focus on patients with a single chronic illness, treated by highly motivated professionals. Whether these benefits are maintained in other settings remains to be seen.

In 2002, the World Health Organization (WHO), in an effort to encourage countries to design and develop strategies to address the management of chronic illnesses, published the Innovative Care for Chronic Conditions (ICCC) Framework,6 which added a health policy perspective to the CCM. The contributions of the ICCC framework to the CCM can be explained at 3 levels. At the macro-level, it highlighted the existence of a positive political environment capable of redirecting services to cater for the demands of chronic illness. At the meso-level, the role of the community continues to be essential, and the notion of integration-coordination of services and resources is particularly emphasized. At micro-level, the interaction between the medical professional and patient is extended to the community. In general, the WHO proposal is based on 8 essential elements (Table 1).

With respect to the reorganization of care, aside from the theoretical models derived from the CCM, it is essential to stratify the population in order to identify individuals at risk of disease, and to predict the needs of patients who already have a chronic illness and so optimize their care. In this regard, the most widely accepted population model is the Kaiser Permanente.7 This consists of a pyramid that stratifies the population into 4 basic levels with respect to the approach to chronic diseases and/or conditions (Table 2).

Stratification goes hand in hand with a comprehensive assessment of the medical, care, functional and social needs of patients, and individualized treatment plans. This model, improved by the King's Fund in the United Kingdom,8 was finally adopted by the Spanish National Health System's (SNHS) Chronicity Strategy.2 It aims to optimize resources by adjusting care interventions to the complexity of the patient, and ensuring a positive cost-effectiveness balance. Healthy people or those with known risk factors should be encouraged to take responsibility for their own health, and should receive education in preventive measures. Those with a low complexity chronic illness should receive self-management support. Disease management is considered for moderately complex patients needing integrated management with multidisciplinary care. Developing integrated, computerized care processes that guarantee adherence to clinical practice guidelines is probably the best approach for disease management. Computerization and decision aids seem to be essential to reduce variability, provide individualized care and monitor outcomes. Finally, case management is based on a process of individualized assessment, planning and coordination. Some new professional profiles, such as the nurse case manager, have arisen in this context. Information and communication technology may also be helpful in monitoring some of these home-care patients.

In 2012, the Spanish Ministry of Health published their National Health System Chronicity Strategy,2 a document that represents a change of approach in the SNHS. The new system will be patient-centered instead of disease-centered. It will address the needs of the population as a whole and each individual in particular to give the best and most efficient healthcare, guarantee continuity of care, adapt to disease progression in the patient, and encourage personal autonomy. The Strategy proposes various priority organizational changes to improve the approach to chronic disease (Table 3). Most Spanish regions have already developed their specific programs. Fig. 2 shows, by way of example, the integrated care process for chronically ill patients in the Valencia region of Spain.9

Fig. 2.

Integrated process for chronic patient care in the Valencia region of Spain. Source: Strategy for chronic patient care in the Valencia region of Spain.9

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One of the chronic diseases with the greatest social, healthcare and economic impact is COPD. Its huge prevalence (10.2% of the population aged over 40 years), high mortality (fifth cause of death in Spain), frequent association with other chronic conditions, and use of resources (0.2% of the gross domestic product) make COPD a “paradigm of chronicity”.10

Although clinical practice guidelines propose a therapy maintenance approach aimed at improving symptoms and preventing risk, COPD patient care is often based on reactive rescue strategies, generally aimed at controlling exacerbations. As mentioned above, this approach is insufficient for a chronic, progressive disease involving multiple comorbidities, and in which major deficiencies have been detected. These include problems with diagnosis (both under-diagnosis, which affects 73% of COPD patients,11 and over-diagnosis, which occurs in up to 30% of our patients12), significant variability in healthcare practices,13,14 scant adherence to clinical practice guidelines with overuse of some drugs,15 poor implementation of respiratory rehabilitation therapies, the strong influence of comorbidities or the need for integrated, coordinated care. To address these issues, redesigning chronic disease management around proactive, more patient-centered (patient management) clinical practice, with greater focus on home ambulatory care and treatment planning, could potentially improve control of these types of diseases, facilitating coordination of care and reducing costs.

Despite this general approach, and although the partial or full use of the CCM has been beneficial in some settings, the fact remains that there is still little evidence to support the efficiency of these types of interventions in COPD patients. Three systematic reviews have shown clinical benefits, finding a significant reduction in both exacerbations requiring medical attention, and in the frequency of hospitalizations, improvements in exercise tolerance and shorter hospital stays.16–18 In a fourth meta-analysis, Boland et al.19 also showed a reduction in direct costs, with savings of €1060 (95% CI: €80–€2040) per patient and year in hospitalization costs and €898 (95% CI: €231–€1566) in costs derived from the use of healthcare services. However, the heterogeneity of the interventions, with underpowered pilot studies, and the scant methodological use of clinical trials make it difficult to draw definitive conclusions.

When 2 or more components of the CCM are included, the programs provide satisfactory results.16,17 However, the benefit of only including a single element is more equivocal. Educational programs and action plans have been particularly controversial. While some systematic reviews show good results,20 one recent clinical trial has even warned of an increase in mortality.21 Success, however, would appear to depend upon using these action plans within an integrated program that seeks collaborative interaction between a well-informed patient (instructed through a more extensive education program) and healthcare professionals.22

Another problem identified in connection with the CCM in COPD is poor population stratification. Focusing integrated care programs that include education, care coordination and telemonitoring on highly complex patients with frequent hospitalizations gives more consistent outcomes, with a reduction in exacerbations and hospital admissions, together with a notable improvement in HRQoL.23 There are barely any results in less complex populations. The use of telemedicine, despite its great potential, also gives heterogeneous results. A Cochrane systematic review24 showed a significant reduction in visits to the emergency department and in hospital admissions. However, it is not known whether this beneficial effect is attributable to the technology itself, or to the implementation of integrated programs. In a recent randomized trial, Pinnock et al.25 did not find any benefits in telemonitoring between groups following a similar care program.

Most of these studies focus on a single disease, in this case COPD. However, it is very interesting to assess interventions that manage patients with multiple chronic diseases. A randomized trial comparing the use of telemedicine with conventional treatment in 3230 patients with diabetes, heart failure or COPD showed lower mortality (4.6% vs 8.3%; odds ratio: 0.54; 95% CI: 0.39–0.75) and a lower rate of hospital admission (odds ratio: 0.82; 95% CI: 0.70–0.97; P=.017), with lower mortality at 12-month follow-up.26 These findings are very encouraging, although they must be replicated in different settings.

Another chronic respiratory disease with huge social, healthcare and economic impact is asthma, which is also often associated with comorbidities. According to Prosser et al.,27 60% of adult asthmatics have at least one concomitant disease, and 12% have 3 or more. Although chronic illness and aging go hand in hand in many cases, childhood asthma, which affects around 7% of the population, is an example of chronic disease in a young population that shares practically the same challenges as the older population.

Thirty-six percent of asthma patients have “uncontrolled” disease, and an additional 34.1% are “partially controlled”. Uncontrolled patients had poorer HRQoL and greater consumption of healthcare resources, tripling the mean cost per patient.28 According to the AsmaCost study, the annual cost of asthma in Spain is between €1480 and €3022 million.29 The mean cost per patient and year is estimated to be €1726, which varies according to the severity of the asthma, ranging from €959 for mild asthma to €2635 for severe asthma. The direct healthcare costs are mainly derived from hospital admissions and poor disease control.

Global strategies such as those proposed in the CCM can facilitate the objective of achieving and maintaining control in the asthmatic patient. Compared to COPD, fewer experiences have been amassed in asthma and CCM, and there is greater heterogeneity. Mehuys et al.,30 in a randomized trial in which education on medication use was offered and pharmacists were also involved in disease monitoring, found a greater reduction in the need for rescue medication, with fewer night-time awakenings, greater adherence to maintenance medication and better inhaler technique. Armor et al.,31 in a similar study, also found better asthma control. As in COPD, programs that include multiple elements of the CCM give better results, and in this context the benefits of educational programs have been widely reported.32 However, not all results are consistent, and some studies found no significant benefits.

Apart from COPD and asthma, the principles of chronicity can potentially be applied to many other chronic respiratory diseases, such as sleep apnea–hypopnea syndrome, bronchiectasis, chronic diffuse interstitial diseases or chronic respiratory failure. However, cumulative scientific evidence remains limited. Recently, the American Association of Sleep Technologists33 proposed stratifying sleep studies according to patient complexity and applying principles of integrated treatment, including patient education, adherence monitoring and distance follow-up. Some authors are conducting integrated studies on sleep units and primary care to facilitate diagnosis and coordination of care,34 and much is being done to develop the use of telemedicine for a variety of interventions in this setting, ranging from diagnosis to adherence monitoring.35,36

For decades, the treatment of chronic respiratory failure (oxygen therapy and/or non-invasive ventilation), irrespective of the specific underlying disease, has been an example of home-based care that includes a clearly patient- and family-centered care reorganization. Integrated nursing care, health education, and more recently distance monitoring, have also been developed in the context of chronic respiratory failure. Attempts are also being made to decentralize other respiratory therapies such as rehabilitation, to switch the focus to home-based care with a closer, more personalized approach, where information and communication technology may also be of inestimable help.37 However, despite these examples, there is still no integrated approach that includes all the components of the CCM in the management of these diseases.