Characteristics and Service Utilization by Complex Chronic and Advanced Chronic Patients in Catalonia: A Retrospective Seven-Year Cohort-Based Study of an Implemented Chronic Care Program

• Main Authors: Sebastià J. Santaeugènia, Joan C. Contel, Emili Vela, Montserrat Cleries, Paloma Amil, Eva M. Melendo-Azuela, Esther Gil-Sánchez, Victoria Mir, Jordi Amblàs-Novellas
• Format: Article
• Language: English
• Published: MDPI AG 2021-09-01
• Series: International Journal of Environmental Research and Public Health
• Subjects: chronic care; integrated care; geriatric care; palliative care; primary health care; multimorbidity
• Online Access: https://www.mdpi.com/1660-4601/18/18/9473
• ISSN: 1661-7827; 1660-4601

The Chronic Care Program introduced in Catalonia in 2011 focuses on improving the identification and management of complex chronic (CCPs) and advanced chronic patients (ACPs) by implementing an individualized care model. Its first stage is their identification based on chronicity, difficult clinical management (i.e., complexity), and, in ACPs, limited life prognosis. Subsequent stages are individual evaluation and implementation of a shared personalized care plan. This retrospective study, including all CCPs and ACPs identified in Catalonia between 2013 and 2019, was aimed at describing the characteristics and healthcare service utilization among these patients. Data were obtained from an administrative database and included sociodemographic, clinical, and service utilization variables and morbidity-associated risk according to the Adjusted Morbidity Groups (GMA) stratification. During the study period, CCPs’ and ACPs’ prevalence increased and was higher in lower-income populations; most cases were women. CCPs and ACPs had all comorbidities at higher frequencies, higher utilization of healthcare services, and were more frequently at high risk (63% and 71%, respectively) than age-, sex-, and income level-adjusted non-CCP (23%) and non-ACP populations (30%). These results show effective identification of the program’s target population and demonstrate that CCPs and ACPs have a higher burden of multimorbidity and healthcare needs.