Development of the COMIC Model for the comprehensive evaluation of integrated care interventions

摘要

Introduction: Integrated care is expected to contribute to improved health outcomes, better patient experiences and increased cost effectiveness, but so far, findings have been mixed. Our objective was to develop a model for the comprehensive evaluation of integrated care interventions that provides insights into when, why and how successful outcomes can be achieved. Methods: A preliminary model was developed based on the Context-Mechanism-Outcome Model and further developed based on its application to a literature review, two case studies and an expert questionnaire. Results : The COMIC Model for studying the Context, Outcomes and Mechanisms of Integrated Care interventions assumes that an intervention is introduced using certain mechanisms (categorised according to the Chronic Care Model), which are met with particular context factors (described by barriers and facilitators and categorised according to the Implementation Model), which combined, contribute to specific outcomes (categorised by the WHO dimensions of quality of care). Discussions: Using the COMIC Model makes it possible to comprehensively study the interplay of the mechanisms, context and outcomes of integrated care interventions and thereby provides insights into when, why and how integrated care contributes to improved outcomes. As such, the COMIC Model does not in itself propose ‘what works’ but makes it possible for people involved in the implementation of integrated care to find the answer to what works, when and why themselves. Since the COMIC Model supports comprehensive and explicit descriptions of how specific context factors shaped the implementation of an intervention, evaluations conducted in one setting are likely to also provide lessons learned that are of added value to other organisations in other settings. Conclusions: The COMIC Model makes it possible to (1) comprehensively analyse the mechanisms, context and outcomes of a specific case, (2) to make the relationships between the mechanisms, context and outcomes within each case visible, and (3) to compare two cases to each other in a systematic way that adds value to the analysis. Lessons learned : The COMIC Model is expected to be of relevance to practitioners and patients involved in the delivery, implementation and receipt of integrated health services, who experience the complexity of health service innovations in their daily professional and personal lives. The COMIC Model can be an important supporting tool to structure this complexity and thereby make it manageable. Limitations: There was no involvement of patients in the development of the model. This should be remedied in future applications, which must include patient interviews along with practitioner and other stakeholder interviews. Suggestions for future research : In its current form, the COMIC Model is mainly targeted at scientists and therefore requires translation to a practice tool to be used by practitioners and patients in their own practice setting. Future research is needed to explore how a practice version of the COMIC Model can be made more accessible to practitioners and patients by using appropriate language, including relatable examples and adopting a different format than a scientific publication.