La gestione della cronicità nelle aziende sanitarie: una rassegna della letteratura

Titolo Rivista MECOSAN
Autori/Curatori Maria Chiara Demartini, Valentina Beretta
Anno di pubblicazione 2021 Fascicolo 2020/116
Lingua Italiano Numero pagine 24 P. 7-30 Dimensione file 388 KB
DOI 10.3280/MESA2020-116002
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FrancoAngeli è membro della Publishers International Linking Association, Inc (PILA)associazione indipendente e non profit per facilitare (attraverso i servizi tecnologici implementati da CrossRef.org) l’accesso degli studiosi ai contenuti digitali nelle pubblicazioni professionali e scientifiche

Una delle principali sfide attuali in ambito sanitario riguarda la gestione integrata delle patologie croniche. In questo contesto, le aziende sanitarie devono bilanciare la gestione efficace della cronicita, da un lato, con il contenimento dei costi legato alle politiche di austerity, dall’altro. Date le diverse formule presenti per poter progettare percorsi di cura integrati per la gestione delle patologie croniche, questo studio ha l’obiettivo di analizzare la letteratura precedente sul tema e identificare spunti per ricerca futura.;

Keywords:Cronicita, aziende sanitarie, rassegna della letteratura

  1. Busse R. et al. (2010). Tackling chronic disease in Europe: strategies, interventions and challenges, Observatory Studies. WHO Regional Office Europe.
  2. Campbell H. et al. (1998). Integrated care pathways. Bmj, 316(7125): 133-137.
  3. Campbell N.C. et al. (2007). Designing and evaluating complex interventions to improve health care. Bmj, 334(7591): 455-459.
  4. Casalini F. et al. (2017). Nuovi strumenti di management per la gestione integrata dei percorsi assistenziali dei pazienti cronici. Mecosan, 102: 35-59.
  5. Celler B. et al. (2018). Patient adherence to scheduled vital sign measurements during home telemonitoring: analysis of the intervention arm in a before and after trial. JMIR medical informatics, 6(2): e15.
  6. Celler B.G., Lovell N.H. and Chan D.K.Y. (1999). The potential impact of home telecare on clinical practice. Medical Journal of Australia, 171(10): 518-521.
  7. Cesta T. and Cohen E. (1993). Nursing case management from concept to evaluation. St. Louis: Mosby.
  8. Chow J.S.F. and Gonzalez-Arce V.E. (2019). Learnings from implementing telemonitoring-the LITE study. Journal of Integrated Care. Emerald Publishing Limited.
  9. Chow J.S.F. et al. (2018). Retrospective analysis of telemonitoring in Wollondilly, Australia. Journal of Integrated Care. Emerald Publishing Limited.
  10. Chunharas S. (2006). An interactive integrative approach to translating knowledge and building a “learning organization” in health services management. Bulletin of the World Health Organization, 84: 652-657.
  11. Coleman K. et al. (2009). Evidence on the chronic care model in the new millennium. Health affairs, 28(1): 75-85.
  12. Couturier Y. (2019). Leading change in the large-scale implementation of a service integration model in Québec. International Journal of Integrated Care (IJIC), 19.
  13. Cruz J., Brooks D. and Marques A. (2014). Home telemonitoring effectiveness in COPD: a systematic review. International Journal of Clinical Practice, 68(3): 369-378.
  14. Currell R. et al. (2000). Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 2. DOI: 10.1002/14651858.CD002098
  15. Dabelea D. et al. (2005). Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort: Kaiser Permanente of Colorado GDM Screening Program. Diabetes care, 28(3): 579-584.
  16. Dario C. et al. (2016). “Assessment of patients” perception of telemedicine services using the service user technology acceptability questionnaire. International journal of integrated care, 16(2).
  17. Devers K.J. et al. (1994). Implementing organized delivery systems: an integration scorecard. Health Care Management Review, 19(3): 7-20.
  18. Disis M.L. and Slattery J.T. (2010). The road we must take: multidisciplinary team science. Science translational medicine, 2(22): 22cm9-22cm9.
  19. Dowd S.B. (2000). Organizational learning and the learning organization in health care. Hospital materiel management quarterly, 21(3): 1-3.
  20. Eccher C. et al. (2020). TreC platform. An integrated and evolving care model for patients’ empowerment and data repository. Journal of Biomedical Informatics, 102: 103359.
  21. Heritage J. and Maynard D.W. (2006). Communication in medical care: Interaction between primary care physicians and patients. Cambridge: Cambridge University Press.
  22. Light D. and Dixon M. (2004). Making the NHS more like Kaiser Permanente. Bmj, 328(7442): 763-765.
  23. Emanuel E., Tanden N., Altman S., Armstrong S., Berwick D., de Brantes F., Calsyn M., Chernew M., Colmers J., Cutler D., Daschle T., Egerman P., Kocher B., Milstein A., Oshima Lee E., Podesta J.D., Reinhardt U., Rosenthal M., Sharfstein J., Shortell S., Stern A., Orszag P.R., Spiro T. (2012). A systemic approach to containing health care spending. N Engl J Med., Sep 6; 367(10): 949-54.
  24. EU, E.U. (2013). A compilation of Good Practices – Integrated care for chronic diseases. https://ec.europa.eu/eip/ageing/library/compilation-good-practices-integrated-care-chronic-diseases-second-edition_en.
  25. Flanagan S., Damery S. and Combes G. (2017). The effectiveness of integrated care interventions in improving patient quality of life (QoL) for patients with chronic conditions. An overview of the systematic review evidence. Health and quality of life outcomes, 15(1): 1-11.
  26. Fletcher H. et al. (1984). Measuring the Continuity and Coordination of Medical Care in a System Involving Multiple Providers. Medical Care, 22(5): 403-411. – Available at: http://www.jstor.org/stable/3764953.
  27. Frenk J. et al. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The lancet, 376(9756): 1923-1958.
  28. Fusco F. and Marsilio M. (2020). Co-production in health policy and management: a comprehensive bibliometric review. BMC Health Services Research, pp. 1-16.
  29. Gary T.L. et al. (2003). Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Preventive medicine, 37(1): 23-32.
  30. Geraedts M. et al. (2020). Development of an indicator set for the evaluation of the population-based integrated healthcare model “Gesundes Kinzigtal”. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen, 150: 54-64.
  31. Gigantesco A. and Giuliani M. (2011). Quality of life in mental health services with a focus on psychiatric rehabilitation practice. Ann Ist Super Sanità, 47(4): 363-372. DOI: 10.4415/ANN
  32. Gillies R.R. et al. (1993). Conceptualizing and measuring integration: findings from the health systems integration study. Journal of Healthcare Management, 38(4): 467.
  33. Giorgi G. (2018). L’esito delle cure specialistiche e riabilitative integrate di multi-patologie e cronicità. Mecosan, 105: 77-110.
  34. Glasgow R.E. et al. (2001). Does the chronic care model serve also as a template for improving prevention?. The Milbank Quarterly, 79(4): 579-612.
  35. Greco M.T. and Russo A.G. (2017). Valutazione del modello CREG utilizzato dalla ATS della Città Metropolitana di Milano per la gestione delle malattie croniche nella medicina generale. Mecosan, 101: 31-50.
  36. Greenhalgh T. et al. (2005). Storylines of research in diffusion of innovation: a meta-narrative approach to systematic review. Social science & medicine, 61(2): 417-430.
  37. Gröne O. and Garcia-Barbero M. (2001). Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. International journal of integrated care, 1.
  38. Ham C. et al. (2003). Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. Bmj, 327(7426): 1257.
  39. Henry B.M. and Lippi G. (2020). Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID-19) infection. International Urology and Nephrology, 52(6): 1193-1194.
  40. Holden K. et al. (2016). Development of a culturally-centered integrated care model: educational implications for researchers, clinicians, patients, and community members. In Edelearn16 Proceedings, IATED, pp. 6535-6543.
  41. Hroscikoski M.C. et al. (2006). Challenges of change: a qualitative study of chronic care model implementation. The Annals of Family Medicine, 4(4): 317-326.
  42. Hudon C. et al. (2016). The Chronic Disease Self-Management Program: the experience of frequent users of health care services and peer leaders. Family practice, 33(2): 167-171.
  43. Iles V. and Cranfield S. (2004). Developing change management skills. A Resource for Health Care Professionals and Managers. London, UK: NHS Service Delivery and Organisation Research and Development Programme.
  44. Johansson G., Eklund K. and Gosman-Hedström G. (2010). Multidisciplinary team, working with elderly persons living in the community: a systematic literature review. Scandinavian Journal of Occupational Therapy, 17(2): 101-116.
  45. Johnston B. et al. (2000). Outcomes of the Kaiser Permanente tele-home health research project. Archives of family medicine, 9(1): 40.
  46. Kass N.E. (2001). An Ethics Framework for Public Health, 91(11).
  47. Katon W. et al. (1995). Collaborative management to achieve treatment guidelines: impact on depression in primary care. Jama, 273(13): 1026-1031.
  48. Kayser L. et al. (2018). Theory and practice in digital behaviour change: a matrix framework for the co-production of digital services that engage, empower and emancipate marginalised people living with complex and chronic conditions. In Informatics. Multidisciplinary Digital Publishing Institute, p. 41.
  49. Kazandjian V.A. and Lied T.R. (1999). Healthcare performance measurement: systems design and evaluation. Milwaukee, WI: ASQ Quality Press.
  50. Kesson E.M. et al. (2012). Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. Bmj, 344: e2718.
  51. Kim H.Y. et al. (2018). Health service utilization, unmet healthcare needs, and the potential of telemedicine services among Korean expatriates. Globalization and health, Springer, 14(1): 120.
  52. Kitchen P.J. and Daly F. (2002). Internal communication during change management. Corporate Communications: An International Journal, 7: 46-53.
  53. Klinga C. et al. (2018). Understanding the dynamics of sustainable change: A 20-year case study of integrated health and social care. BMC health services research, 18(1): 1-12.
  54. Kodner D.L. and Spreeuwenberg C. (2002). Integrated care: meaning, logic, applications, and implications – a discussion paper. International journal of integrated care, 2.
  55. Kreitner S. et al. (2003). Assessing the competencies and training needs for public health professionals managing chronic disease prevention programs. Journal of Public Health Management and Practice, 9(4): 284-290.
  56. Krieger J. and Higgins D.L. (2002). Housing and Health: Time Again for Public Health Action, 92(5).
  57. Laine C. and Davidoff F. (1996). Patient-Centered Medicine: A Professional Evolution. JAMA, 275(2): 152-156.
  58. Leatherman S. and Sutherland K. (2003). The quest for quality in the NHS. A mid-term evaluation of the 10-year quality agenda. London: The Stationery Office.
  59. Lester H. et al. (2010). The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators. Bmj, 340: c1898.
  60. Lion K.C. and Raphael J.L. (2015). Partnering Health Disparities Research With Quality Improvement Science in Pediatrics. Pediatrics, 135(2): 354-361.
  61. Li W. et al. (2020). COVID-19 in persons with chronic myeloid leukaemia. Leukemia, 34(7): 1799-1804.
  62. Lorig K.R., Ritter P. et al. (2001). Chronic disease self-management program: 2-year health status and health care utilization outcomes. Medical care, 39: 1217-1223.
  63. Adams S.G. et al. (2007). Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management. Archives of internal medicine. American Medical Association, 167(6): 551-561.
  64. Ahgren B. and Axelsson R. (2005). Evaluating integrated health care: a model for measurement. International journal of integrated care. Ubiquity Press, 5.
  65. Ahluwalia S.C. et al. (2019). How are medical groups identified as high-performing? The effect of different approaches to classification of performance. BMC health services research, 19(1): 500.
  66. Al-Abri R. (2007). Managing change in healthcare. Oman medical journal, 22(3): 9.
  67. Al-Abri R.K. and Al-Hashmi I.S. (2007). The learning organisation and health care education. Sultan Qaboos University Medical Journal, 7(3): 207.
  68. Alter C. and Hage J. (1993). Organizations working together. California: Sage Publications, Inc.
  69. Anderson R.M. and Funnell M.M. (2010). Patient empowerment: Myths and misconceptions. Patient Education and Counseling, 79(3): 277-282.
  70. Lorig K.R., Sobel D.S. et al. (2001). Effect of a self-management program on patients with chronic disease. Effective clinical practice: ECP, 4(6): 256-262.
  71. Lorig K.R. et al. (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Medical care, 37: 5-14.
  72. Mainz J. (2003). Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care, 15(6): 523-530.
  73. Majumdar S.R. et al. (2011). Nurse case-manager vs multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study. Osteoporosis international, 22(1): 223-230.
  74. Maliski S.L., Clerkin B. and Litwin M.S. (2004). Describing a nurse case manager intervention to empower low-income men with prostate cancer. In Oncology nursing forum.
  75. Marcelli S. et al. (2017). Chronic care model and cost reduction in initial health: a new approach for satisfaction and improvement of chronicity. Geriatric Care, 3(3).
  76. Martí T. et al. (2016). Risk stratification tools for integrated care: appraisal, deployment and impact in Europe. International Journal of Integrated Care (IJIC), 16(6).
  77. Mays N., Roberts E. and Popay J. (2001). Synthesising research evidence. Studying the organisation and delivery of health services: Research methods, 220.
  78. Menichetti J., Pitacco G. and Graffigna G. (2019). Exploring the early‐stage implementation of a patient engagement support intervention in an integrated‐care context – A qualitative study of a participatory process. Journal of clinical nursing, 28(5-6): 997-1009.
  79. Mohr J.J. (2005). Creating a safe learning organization. Frontiers of Health Services Management, 22(1): 41.
  80. Monti S. et al. (2020). Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies. Liver Transplantation, 26(6): 832-834.
  81. Morrisey M.A. et al. (1999). The Effects of Managed Care on Physician and Clinical Integration in Hospitals. Medical Care, 37(4): 350-361. – Available at: http://www.jstor.org/stable/3767444.
  82. Nolte E. and McKee M. (2008). Caring for people with chronic conditions: a health system perspective. UK: McGraw-Hill Education.
  83. Odewumi L. (2019). Why bother about governance-exploring interpretation of professionals involved in the implementation of integrated care programmes in community healthcare organisations. International Journal of Integrated Care (IJIC), 19.
  84. Pariser P. et al. (2019). Connecting people with multimorbidity to interprofessional teams using telemedicine. The Annals of Family Medicine, 17(Suppl 1): S57-S62.
  85. Paré G., Jaana M. and Sicotte C. (2007). Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base. Journal of the American Medical Informatics Association, 14(3): 269-277.
  86. Peeters J.M. et al. (2012). Factors influencing the adoption of home telecare by elderly or chronically ill people: a national survey. Journal of Clinical Nursing, 21(21-22): 3183-3193.
  87. Pelletier A.C., Jethwani K., Bello H., Kvedar J., Grant R.W. (2011). Implementing a web-based home monitoring system within an academic health care network: barriers and facilitators to innovation diffusion. J Diabetes Sci Technol., Jan 1; 5(1): 32-8. DOI: 10.1177/193229681100500105.PMID:21303622;PMCID:PMC3045230
  88. Perrin P.B. et al. (2020). Rapid telepsychology deployment during the COVID-19 pandemic: A special issue commentary and lessons from primary care psychology training. Journal of Clinical Psychology, 76(6): 1173-1185.
  89. Petersen L.A., Woodard L.D., Urech T., Daw C. and Sookanan S. (2006). Does pay-for-performance improve the quality of health care?. Annals of internal medicine, 145(4): 265-272.
  90. Piatt G.A. et al. (2006). Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes care, 29(4): 811-817.
  91. Piterman L., Koritsas S. (2005). Part II. General practitioner – specialist referral process. Intern Med J, 35: 491-6.
  92. Popay J., Rogers A. and Williams G. (1998). Rationale and standards for the systematic review of qualitative literature in health services research. Qualitative health research, 8(3): 341-351.
  93. Punamäki R.-L. et al. (2007). Use of information and communication technology (ICT) and perceived health in adolescence: The role of sleeping habits and waking-time tiredness. Journal of Adolescence, 30(4): 569-585.
  94. Purbey S., Mukherjee K. and Bhar C. (2007). Performance measurement system for healthcare processes. International Journal of Productivity and Performance Management, 56: 241-251.
  95. Reeves S. et al. (2013). Interprofessional education: effects on professional practice and healthcare outcomes. Cochrane Database of systematic reviews, 3.
  96. Reilly J.J. et al. (2003). Health consequences of obesity. Archives of disease in childhood, 88(9): 748-752.
  97. Reimanis C.L., Cohen E.L. and Redman R. (2001). Nurse case manager role attributes: Fifteen years of evidence-based literature. Professional Case Management, 6(6): 230-239.
  98. Remus K.E. et al. (2016). A Chronic Disease Management Student–Faculty Collaborative Practice: Educating Students on Innovation in Health Care Delivery. Academic Medicine, 91(7): 967-971.
  99. Rompen L. et al. (2020). Introduction of network-based healthcare at Kaiser Permanente. Journal of Parkinson’s Disease, 10(1): 207-212.
  100. Rosen R. (2007). Improving chronic disease management. An Anglo-American exchange, November, pp. 1-20.
  101. Rouyard T. et al. (2018). Risk attitudes of people with “manageable” chronic disease: An analysis under prospect theory. Social Science & Medicine, 214: 144-153.
  102. Sayani S. et al. (2019). Addressing cost and time barriers in chronic disease management through telemedicine: an exploratory research in select low-and middle-income countries. Therapeutic advances in chronic disease, 10: 2040622319891587.
  103. Schaper L.K. and Pervan G.P. (2007). ICT and OTs: A model of information and communication technology acceptance and utilisation by occupational therapists. International Journal of Medical Informatics, 76: S212-S221.
  104. Schett G., Sticherling M. and Neurath M.F. (2020). COVID-19: risk for cytokine targeting in chronic inflammatory diseases?. Nature Reviews Immunology, 20(5): 271-272.
  105. Schuttner L., Wong E.S., Rosland A.M., Nelson K. and Reddy A. (2020). Association of the Patient-Centered Medical Home Implementation with Chronic Disease Quality in Patients with Multimorbidity. Journal of General Internal Medicine, 35(10): 2932-2938.
  106. Segato F. and Masella C. (2017). Integrated care in action: opening the “black box” of implementation. The International journal of health planning and management, 32(1): 50-71.
  107. Sharma S. and Khadka A. (2019). Role of empowerment and sense of community on online social health support group. Information Technology & People. Emerald Publishing Limited.
  108. Shaw L.M. et al. (2011). Qualification of the analytical and clinical performance of CSF biomarker analyses in ADNI. Acta neuropathologica, 121(5): 597-609.
  109. Shaw S., Rosen R. and Rumbold B. (2011). What is integrated care. London: Nuffield Trust, 7.
  110. Shukla R.K. (1985). A longitudinal approach for measuring integration and continuity of nursing care. Inquiry, 22(4): 426-32.
  111. Sidney S. et al. (2005). COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program. Chest, 128(4): 2068-2075.
  112. Silvestre A.-L., Sue V.M. and Allen J.Y. (2009). If you build it, will they come? The Kaiser Permanente model of online health care. Health Affairs, 28(2): 334-344.
  113. Simoens S. (2001). The dimensions and determinants of integration in primary care. Aberdeen: University of Aberdeen.
  114. Singh J. (2005). Collaborative networks as determinants of knowledge diffusion patterns. Management science, 51(5): 756-770.
  115. Smeenk F.W.J.M. et al. (2000). Effects of transmural care on coordination and continuity of care. Patient education and counseling, 41(1): 73-81.
  116. Sockalingam S. et al. (2020). Developing a Framework of Integrated Competencies for Adaptive Expertise in Integrated Physical and Mental Health Care. Teaching and Learning in Medicine, 32(2): 159-167. DOI: 10.1080/10401334.2019.1654387
  117. Stewart M., Brown J.B., Donner A., McWhinney I.R., Oates J., Weston W.W., Jordan J. (2000). The impact of patient-centered care on outcomes. J Fam Pract., Sep; 49(9): 796-804. PMID: 11032203.
  118. Strandberg-Larsen M. and Krasnik A. (2009). Measurement of integrated healthcare delivery: a systematic review of methods and future research directions. International journal of integrated care, 9.
  119. Tozzi V. et al. (2019). Position paper sulle politiche per la cronicità e sugli interventi per la gestione dello scompenso cardiaco. Mecosan, 111: 83-111.
  120. Turvey C. and Fortney J. (2017). The use of telemedicine and mobile technology to promote population health and population management for psychiatric disorders. Current Psychiatry Reports, 19(11): 88.
  121. Valentijn P.P. et al. (2013). Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. International journal of integrated care, 13.
  122. van der Geer E., van Tuijl H.F.J.M. and Rutte C.G. (2009). Performance management in healthcare: performance indicator development, task uncertainty, and types of performance indicators. Social science & medicine, 69(10): 1523-1530.
  123. van der Linden B.A., Spreeuwenberg C. and Schrijvers A.J.P. (2001). Integration of care in The Netherlands: the development of transmural care since 1994. Health policy, 55(2): 111-120.
  124. van Dulmen S. et al. (2007). Patient adherence to medical treatment: a review of reviews. BMC Health Services Research, 7(1): 55. DOI: 10.1186/1472-6963-7-55
  125. Varkey P., Reller M.K. and Resar R.K. (2007). Basics of Quality Improvement in Health Care. Mayo Clinic Proceedings, 82(6): 735-739. DOI: 10.4065/82.6.735
  126. Vasi S. et al. (2020). Building quality chronic illness care: implementation of a web-based care plan. Australian Journal of Primary Health, 26(2): 173-177.
  127. Armitage G.D. et al. (2009). Health systems integration: state of the evidence. International journal of integrated care, 9.
  128. Atwal A. and Caldwell K. (2006). “Nurses” perceptions of multidisciplinary team work in acute health‐care. International journal of nursing practice, 12(6): 359-365.
  129. Baillieu R. et al. (2020). Impact of health information technology optimization on clinical quality performance in health centers: A national cross-sectional study. PloS one, 15(7): e0236019.
  130. Barlow J.H., Bancroft G.V. and Turner A.P. (2005). Self-management training for people with chronic disease: a shared learning experience. Journal of Health Psychology, 10(6): 863-872.
  131. Barr V. et al. (2003). The expanded chronic care model. Hosp Q, 7(1): 73-82.
  132. Barzan E. et al. (2017). La presa in carico dei pazienti cronici in Lombardia: quale governance e quali indeterminatezze nel modello. Mecosan, 103: 31-48.
  133. Bashshur R.L., Reardon T.G. and Shannon G.W. (2000). Telemedicine: A New Health Care Delivery System. Annual Review of Public Health, 21(1): 613-637.
  134. Beretta V. and Crea G. (2020). Mapping Chronic Diseases in Italy: Trends from the last 20 years. Economia Aziendale Online, 10(4): 585-606.
  135. Best A., Stokols D., Green L.W., Leischow S., Holmes B., Buchholz K. (2003). An integrative framework for community partnering to translate theory into effective health promotion strategy. Am J Health Promot., Nov-Dec; 18(2):168-76. DOI: 10.4278/0890-1171-18.2.168.PMID:14621414
  136. Black S. et al. (2004). Postlicensure surveillance for pneumococcal invasive disease after use of heptavalent pneumococcal conjugate vaccine in Northern California Kaiser Permanente. The Pediatric infectious disease journal, 23(6): 485-489.
  137. Bodenheimer T., Chen E. and Bennett H.D. (2009). Confronting the growing burden of chronic disease: can the US health care workforce do the job?. Health affairs, 28(1): 64-74.
  138. Bodenheimer T. and Handley M.A. (2009). Goal-setting for behavior change in primary care: an exploration and status report. Patient education and counseling, 76(2): 174-180.
  139. Bodenheimer T., Wagner E.H. and Grumbach K. (2002a). Improving primary care for patients with chronic illness: the chronic care model, Part 2. Jama, 288(15): 1909-1914.
  140. Bodenheimer T., Wagner E.H. and Grumbach K. (2002b). Improving primary care for patients with chronic illness. Jama, 288(14): 1775-1779.
  141. Bornstein B.H., Marcus D., Cassidy W. (2000). Choosing a doctor: an exploratory study of factors influencing patients’ choice of a primary care doctor. J Eval Clin Pract., Aug; 6(3): 255-62.
  142. Brady T.J. et al. (2013). Peer reviewed: A meta-analysis of health status, health behaviors, and health care utilization outcomes of the chronic disease self-management program. Preventing chronic disease, 10.
  143. Brazil C., Swan S.H., Drobnis E.Z. et al. (2004). Standardized methods for semen evaluation in a multicenter research study. Journal of andrology, 25(4): 635-644.
  144. Brazil C., Swan S.H., Tollner C.R. et al. (2004). Quality control of laboratory methods for semen evaluation in a multicenter research study. Journal of Andrology, 25(4): 645-656.
  145. Brohman K. et al. (2019). Cascading Feedback: A Longitudinal Study of a Feedback Ecosystem for Telemonitoring Patients with Chronic Disease. MIS Quarterly, 43(4).
  146. Browne G. et al. (2004). Conceptualizing and validating the human services integration measure. International journal of integrated care, 4: e03-e03.
  147. Busse R. and Mays N. (2008). Paying for chronic disease care. Caring for people with chronic conditions: a health system perspective. Maidenhead: Open University Press.
  148. Vassalou L. (2001). The learning organization in health-care services: theory and practice. Journal of European Industrial Training, 25: 354-365.
  149. Viktoria Stein K. and Rieder A. (2009). Integrated care at the crossroads-defining the way forward. International journal of integrated care, 9: e10–e10. – Available at: https://pubmed.ncbi.nlm.nih.gov/19513179.
  150. Von Korff M. et al. (1997). Collaborative management of chronic illness. Annals of internal medicine, 127(12): 1097-1102.
  151. Vrijhoef H.J.M. et al. (2001). Adoption of disease management model for diabetes in region of Maastricht. Bmj, 323(7319): 983-985.
  152. Vuik S.I., Mayer E. and Darzi A. (2016). Enhancing risk stratification for use in integrated care: a cluster analysis of high-risk patients in a retrospective cohort study. BMJ open, 6(12).
  153. Wagner E.H., Austin B.T. and Von Korff M. (1996). Organizing care for patients with chronic illness. The Milbank Quarterly, 3: 511-544.
  154. Wang B.B., Wan T.T., Clement J. and Begun J. (2001). Managed care, vertical integration strategies and hospital performance. Health Care Management Science, 4(3): 181-191.
  155. Wan T.T.H., Lin B.Y.-J. and Ma A. (2002). Integration Mechanisms and Hospital Efficiency in Integrated Health Care Delivery Systems. Journal of Medical Systems, 26(2): 127-143.
  156. Wan T.T, and Wang B.B. (2003). Integrated healthcare networks’ performance: a growth curve modeling approach. Health Care Management Science, 6(2): 117-124.
  157. WHO (2006). Gaining Health The European Strategy for the Prevention and Control of Noncommunicable Diseases. https://www.euro.who.int/en/publications/abstracts/gaining-health.-the-european-strategy-for-the-prevention-and-control-of-noncommunicable-diseases.
  158. WHO (2015). Global status report on noncommunicable diseases 2014. Geneva: World Health Organization.
  159. Zhou Y.Y. et al. (2010). Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health affairs, 29(7): 1370-1375.

Maria Chiara Demartini, Valentina Beretta, La gestione della cronicità nelle aziende sanitarie: una rassegna della letteratura in "MECOSAN" 116/2020, pp 7-30, DOI: 10.3280/MESA2020-116002