Managing the performance of general practitioners and specialists referral networks: a system for evaluating the heart failure pathway

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ContentslistsavailableatScienceDirect

Health

Policy

jo u rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Managing

the

performance

of

general

practitioners

and

specialists

referral

networks:

A

system

for

evaluating

the

heart

failure

pathway

Sabina

Nuti

a

_,

_Francesca

_Ferré

a,∗

_,

_Chiara

_Seghieri

a

_,

_Elisa

_Foresi

a

_,

_Therese

_A.

_Stukel

b

a_Laboratorio_Management_e_Sanità,_Istituto_di_Management,_Dipartimento_EMbeDS,_Scuola_Superiore_Sant’Anna_of_Pisa,_Piazza_Martiri_della_Libertà,_33,

56127,Pisa,Italy

b_ICES,_University_of_Toronto,_Canada

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received1April2019 Receivedinrevisedform 16September2019 Accepted5November2019 Keywords:

Heartfailure Clinicalpaths

Referralnetworksofcare Performanceevaluation Integrationofcare

a

b

s

t

r

a

c

t

Highqualitychronicdiseasemanagementrequirescoordinatedcareacrossdifferenthealthcaresettings, involvingmultidisciplinaryteamsofprofessionals,andperformanceevaluationsystemsabletomeasure thiscare.Inter-organizationalperformanceshouldbemeasuredconsideringtheprofessional relation-shipsbetweengeneral practitioners(GPs)andspecialists,whoare usuallylinkedthroughinformal referralnetworks.

Theaimofthispaperistoidentifyandevaluatetheperformanceofnaturallyoccurringnetworksof GPsandhospital-basedspecialistsprovidingcareforcongestiveheartfailure(CHF)patientsinTuscany, Italy.Theanalysisfocusesontheidentificationandclassificationofnetworks,followingCHFpatients (n=15,841)throughprimarycareandinpatientcareusingadministrativedata,andontheassessment ofprocessandoutcomeindicatorsforCHFpatientsinthesereferralnetworks.

WedemonstratetheexistenceofinformallinksbetweenGPsandhospitalsbasedonpatternsofpatient flow.Thesenetworkswhicharenotgeographicallybasedvaryintheintensityofrelationshipsandquality ofcare.Suchreferralnetworksmayrepresentthemosteffectiveaccountabilitylevelforchronicdisease management,sincetheyencompassthemultiplecaresettingsexperiencedbypatients.Overall,an inte-gratedapproachtoevaluationandperformancemanagementthatconsidersthenaturallyoccurringlinks betweenprofessionalsworkingindifferentsettingsmayenablemoreefficient,integratedcareandquality improvements.

1. Introduction

Chronic conditions are becoming increasingly important for healthsystemsworldwide,andaccountforapproximately46%of theglobalburdenofdisease[1].Themanagementofthese condi-tionsposessignificantchallengesforpatients,healthprofessionals, andhealthsystemsmorebroadly.Congestiveheartfailure(CHF) is a chronic diseasewith highprevalence[2], affecting tens of millionsofpatientsworldwide.Itfrequentlyarisesasaresultof ischemicheartdisease(IHD),theworld’sleadingcauseofdeath in2010[3].TheprevalenceofCHFisexpectedtoincreasedueto higherlifeexpectancyandreductionsinacuteIHDmortality[2]. CHFisfrequentlydiagnosedinhospitalizedpatients.Theproper management of CHF involvesboth primary and specialist care, withco-managementofpatientstoensuretheimplementationof

∗ Correspondingauthor.

E-mailaddress:francesca.ferre@santannapisa.it(F.Ferré).

evidence-basedtherapy,effectivemanagement ofcomorbidities, andtimelyfollow-up[4,5].

Improving coordination of care for chronic disease patients reduceshospitalizationrates,increasesqualityoflifeforpatients and improveshealth systemsustainability[6].Multidisciplinary careteamsarerecommendedinCHFguidelines,withtheevidence demonstrating improvedoutcomes,alleviationof suffering,and betterexperienceforpatientsandtheirfamilies[7].Additionally, CHFpatientsmanagedinacoordinatedmannerbyprimarycare andspecialistphysicianshavehighersurvivalratesthanthose fol-lowedonlybyfamilyphysicians[8,9]aswellasreducedhospital readmissionrates[10].

However,primarycareandinpatientsettingstypicallyoperate insilos,wheregeneralpractitioners(GPs)andspecialistsworkin separatesystemswithpoorcommunication,informationand lim-itedsharedresponsibility[11,12].Indeed,performanceevaluation systems (PES) in healthcare favor measures at the organiza-tionallevel,bysettinggoalsandmonitoringperformanceresults, stressingdepartments’productivity(e.g.,volumesandcomplexity)

https://doi.org/10.1016/j.healthpol.2019.11.001

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[13,14]andcreatingcompetitionforresourceallocation.ThesePES limittheabilityofhealthcarestakeholderstoassessperformance throughtheperspectiveofcarepathways[15]andaccordingto thepublicvaluecreationparadigm-whichshouldbethereference paradigmofpublichealthcaresystems[16].Effectiveperformance evaluationsystemsarethereforeneededtomonitorintegratedcare pathwaystoenhancesystemaccountability,reduceunwarranted variation,andimprovequalityofcare.

Accurately measuring the performance of care pathways requires a focus on inter-organizational networks that allow coordinationbetweenhealthprofessionalsacrossorganizational boundaries.Thesenetworks,whichmayormaynotbeofficially constituted,shouldcareforpatientsalongallphasesofthecare pathway.Therelationshipsamongnetworkprovidersare charac-terizedbyinterdependence,complexity,andcontinuouschange. Thesefeatures,plustheabsenceofaclearhierarchy,makestheir assessmentproblematic[17].

Inter-organizationalperformancecanbemeasuredby consider-ingtheprofessionalrelationshipsbetweenGPsandspecialists,who areusuallylinkedthroughinformalreferralnetworkswhichcould bebasedonthecollectiveexperienceofworkingtogether.These informallinksbetweenGPsandhospitalhealthprofessionalsare describedusingpatternsofpatientflowwhichcanbeidentified throughlinked administrativehealthcaredatabases. Webelieve that these primaryand hospital-based specialist carenetworks mayrepresentaneffectivelevelofaccountabilityforhealth sys-temmanagement.Indeed, makingprofessionalsaccountablefor patientstheyhaveincommon[8]bymeasuringperformanceon theiroutcomesandonprocessindicatorscanenhance collabora-tionandintegrationacrossdifferentcaresettings.Ourworkuses thesemulti-specialistcarenetworksasunitsofperformance mea-surement.

2. Measuringandevaluatingintegrationofcareusing administrativedata

Previousstudieshaveidentifiedinformalmulti-specialistcare networksthroughthelinkageofhealthadministrativedata.Bynum etal.[18]developedamethodologytoassignU.S.Medicarepatients andtheambulatoryphysicianswhoservethemtoindividual hos-pitals. Otherworkshows how administrativedata canbeused tounderstand howcare is actually deliveredand organizedby groupsofprimarycaredoctors,andthustomeasurehow prac-titionersareinterconnectedthrough theircare ofpatients[19]. Landonetal.(2012)appliedsocialnetworkanalysistoU.S. Medi-caredatatodefineprofessionalnetworksbasedonpatientsharing among physicians,and alsoexaminedhow suchnetworksvary acrossgeographicareas[20].Stukeletal.(2013)identifiedinformal multispecialtyphysiciannetworksinOntario(Canada),bylinking GPsandspecialiststothehospitalswheremostoftheirpatients wereadmitted[21].

BuildingontheexperienceofOntario,thepresentstudyaimsat identifyingnaturallyoccurringlinksbetweenprimarycare physi-ciansandhospitals-basedspecialistsinvolvedinthemanagement ofCHFinTuscany(Italy)usinghealthadministrativedata. Addition-ally,theperformanceofeachprimaryandspecialistcarenetwork isevaluatedthroughasetofevidence-basedindicatorsforCHFcare thatincludebothprocessandoutcomemeasures.

3. Context

Italy’shealth-caresystemisaregionallybasedNationalHealth Service(NHS),whichprovidesuniversalcoveragelargelyfreeof chargeatthepointofdelivery.Tuscanyisalargeregionincentral Italy,withanon-competitivehealthsystemprovidingprevention

andprimarycareaswellashospitalservices.Theregionalhealth systeminTuscany(TRHS)isresponsibleforthehealthof3.7 mil-lioninhabitants(6.2%oftheItalianpopulation[22])andcomprises threelocalhealthauthoritieswithabout40communityhospitals, fourteachinghospitals,onemono-specialistcardiaccentre,and 34healthdistricts.Thelocalhealthauthoritiesprovidepreventive medicineandpublichealthservices,primarycare,andinpatient andoutpatientcare,whiletheteachinghospitalsfocusonacute careandprofessionaltraining.Primarycarephysiciansarefunded onacapitationbasisandtheiractivityiscoordinatedwiththe ser-vicesprovidedbythehealthdistrict.IntheTRHS,about2,650GPs providefamilymedicineservicesandactasgatekeeperstohigher levelsofcare[23].Multipleprimarycarephysiciansandspecialist networksformacrosstheTRHS,sinceGPscanreferpatientstoany specialist(inpatientandoutpatient),andpatientsarefreetoseek carefromanyprovider.

Recently,theTRHSdevelopedanewformofprimarycare pro-fessionalintegrationatthelocallevel(territory)byadoptingthe TerritorialFunctionalAggregations(AggregazioniFunzionalie Ter-ritoriali-AFTs).AFTsarecompulsorynetworksofGPsexpectedto applyclinicalgovernanceprinciplestocontinuouslyimprovethe qualityofservicesandsafeguardhighstandardsofcare[24]. Cur-rently116AFTs(2017)havebeenestablishedthroughouttheTRHS. Onaverage,eachAFTservesapopulationofabout30,000patients by23GPs[23].OurresearchanticipatesthatthesenetworksofGPs willshowinter-networkvariabilityinoutcomesandprocessesfor thecareofCHFpatients.

4. Materialsandmethods

Adopting the methods of Stukel [21], the identification of primaryandspecialistcarenetworkswasbasedona retrospec-tiveanalysisusingdifferentsourcesofroutinelycollectedhealth administrativedatafromtheTuscanregionfor2014-2016. Specif-ically, theindividuallevel healthdatabases usedinthepresent study include:(i)hospital inpatientdata wheredata arecoded usingthe9th_revision,_ICD9-CM;_(ii)_emergency_care_data;_(iii)

regis-teredpersonsdatabasewhichincludesdataonallpersonsenrolled intheTuscanhealthcaresystemincludingdateofbirth,dateof death,andassignedprimarycarephysician.Thedifferent adminis-trativedatabaseswerelinkedatindividual(patient)levelthrougha uniqueidentifier.Additionaladministrativedatawereusedto mea-sureperformanceindicators,namelyoutpatientdrugprescription data,usingtheAnatomicalTherapeuticChemical(ATC) classifica-tionsystemandoutpatientcaredata.

DatawereanonymizedattheRegionalHealthInformation Sys-temOfficewhereeachpatientwasassignedanencryptedunique identifier.Thestudywascarriedoutincompliancewiththe Ital-ianlawonprivacy,andapprovalbyanEthicsCommitteewasnot required.

The datamanagement andtheanalyseswere runusingSAS version9.4(SASInstitute).

4.1. Cohortselectionandprimaryandspecialistcarenetworks identification

ThemultispecialtyphysiciannetworksforCHFcarewere iden-tifiedusingatwo-stepprocess:usinghealthadministrativedata, acohortofpatientswithcardiacconditionswasselectedandeach patientassignedtohis/herGP(phase1);eachGPwasthenassigned to the hospital where most of his/her patients were admitted foranycardiaccondition(referencehospital)(phase2).Current administrativedatadonotallowtheidentificationofthehospital specialistwhovisitedtheCHFpatientinhospitalthereforelinkages betweenproviderswerecreatedbetweentheGPandthehospital.

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Thecohortofcardiacpatientsinphase1wasidentifiedby select-ingallresidentsaged18–100yearswhohadatleastoneplannedor unplannedhospitalizationforheartdisease,arrhythmiaorcardiac decompensationinanypublichospitalinTuscanyinthethree-year periodfromJanuary1st₂₀₁₄_to_December₃₁st₂₀₁₆_(the

diagnos-ticcodesfortheidentificationofCHFpatientsarereportedinthe OnlineAppendix).Inphase1weincludedallpatientshospitalized foranycardiac conditionincludingCHF,sincewe hypothesised that linkages betweentheGP and thehospital-based specialist wouldholdforsimilarclinicalconditions(i.e.,thereference spe-cialistwouldbethesameforallcardiomyopathies).Thisconsiders agreaternumberofcardiacconditionsallowingamoreaccurate identificationofGPsandhospital-basednetworks.

Thestudycohortincluded51,760patientsand67,674 hospital-izationsforcardiacconditions.Thepatientswerethenassignedto theirGPs.PatientswhochangedGPduringtheobservationperiod wereassigned totheGPwhoprovided mostof thecareinthe observationperiod. For each GP,wecalculated thedistribution ofadmissionsofhis/herpatientstoallTuscanhospitalsoverthe 3-yearperiod.Basedonthisdistribution,GPswereassignedtoa ref-erencehospital-thehospitalwherethemajorityoftheirpatients wereadmitted(phase2).Throughthismethodweidentified2,881 linkagesofGPtohospitalwhichcomprised51,760patientswith cardiacconditionsassistedby2,881GPswho,inturn,wereassigned to41referencehospitals.Foreachpair,weclassifiedthe“strength” oftheprofessionallinkage(GPtohospital)asstrong,moderateand weak.Stronglinkageswerethoseforwhichatleast60%ofthe patientsof aGPwereadmittedtothesamehospital; moderate linkageswerethosewhere40%–60%wereadmittedtothesame hospital;andweaklinkageswerethosewherelessthan40%ofthe patientswerehospitalizedtothesamehospital,indicatingthatGPs tendedtoreferhis/herCHFpatientstodifferenthospitals(phase3). Allanalyseswereperformedusingthestrongestlinkage net-worksonly,sincewehypothesizedthattheyconstitutethehighest hospitaladmissionloyaltytoallowforoptimalperformance bench-marking and continuity of care. Out of the 2,881 linkages, we identified2,062strongGP-hospitallinkages.

TheperformanceevaluationwasrestrictedtoCHFpatients (car-diacpatientshavingat leastone hospitalizationfor CHF inthe 3-yearperiod)whowereadmittedforCHFtothereferencehospital. Fromthese,weobtained1,965strongGP-hospitallinkageswhich included15,841CHFpatientslinkedto1,965GPsand38reference hospitals.Webasedtheperformanceanalysisonthesenetworks. The diagnostic codes for theidentification of CHF patientsare reportedintheOnlineAppendix.

Finally,weranavalidationtesttoassesshowself-containedthe networkswere.WemeasuredthefrequencyofCHFpatientsthat hadatleastonecardiacoutpatientvisit,oneechocardiographic ser-vice,oroneelectrocardiogramdeliveredinthereferencehospitals inthe3-yearobservationperiod(January1st_,₂₀₁₄_to_December

31st_,_2016)._We_found_that_on_average,_in₇₄ _%_of _the_networks

thereferencehospitalforinpatientserviceswasalsothereference hospitalforoutpatientservices.

4.2. Performancemeasuresregardingheartfailurecareprocess andoutcome

From yearly performance reports of the Tuscan Perfor-manceEvaluationSystem(PESfreelyaccessibleonlineathttp:// performance.santannapisa.it/pes/toscana)thatmeasureandassess multiplehealthcareperformancedimensionsattheproviderand AFTlevels,weselectedevidence-basedindicatorsforCHF.These indicatorshavebeenmeasuredandevaluatedinindividualcare set-tingsandsharedwithpractitionersandpolicy-makerstosupport performanceimprovementandalignmentwiththestrategicgoals ofthehealthcaresystem[25].Publicreportingofbenchmarked

performance,togetherwithclinicalinvolvementindevelopingthe rulesandcriteriaofperformanceindicators,enabletheeffective engagementofprofessionalsindiscussionandfeedbackabout per-formanceandoutcomes.

Theindicators,calculatedfromadministrativedatabases,are: • Medicationadherence:%ofpatientswithtwoormore

prescrip-tionsofbeta-blockerswithinoneyearoftheindexhospitalization (C11a.1.4indicatorcodeonthePESwebplatform).Indeed,recent researchrevealedthebenefitsoftreatingheartfailurepatients withlong-termbeta-blockertherapyespeciallyinpatientswhere thereisaIArecommendation[26].%ofpatientswithtwoormore prescriptionsofACEinhibitorsorARBswithinoneyearofthe indexhospitalization(C11a.1.3indicatorcodeonthePESweb platform);and%ofpatientswithtwoormoreprescriptionsof anti-aldosteronewithinoneyearoftheindexhospitalization. • Outpatientfollow-upduringoneyearpost-index

hospitaliza-tion:%ofpatientsseenbyacardiologistatleastoncewithinone yearoftheindexhospitalization.Evidencereportingthat30-day follow-upafterdischargeisassociatedwithlowerriskof1-year mortality[27]andearlyphysicianfollow-up(within7days)can furtherreducethisriskand30-dayreadmissionrate[28,29].% ofpatientshavingatleastoneechocardiogramwithinoneyear oftheindexhospitalization;%ofpatientswithatleastone mea-surementofB-typenatriureticpeptide(BNP)andN-terminalpro b-typenatriureticpeptide(NT-proBNP)withinoneyearofthe indexhospitalization;and%ofpatientswithatleastone crea-tinine,sodiumandpotassiumlevel measuredwithinoneyear oftheindexhospitalization(C11a.1.2aandC11a.1.2bindicator codesonthePESwebplatform).

• Outcomes:unplannedreadmissionswithin30and180daysafter theindexhospitalizationexcludingpatientwhodiedinhospital; 30and180daymortality(includinghospitalmortality)afterthe indexhospitalization.Theindexhospitalizationwasidentifiedby randomlyselectingonehospitalizationduringthestudyperiod [30].

Outcomeswereindirectlyadjustedbyage,sexandElixhauser indexthroughamultiplelogisticregression.Tocomputethe Elix-hauserindex,weadoptedtheComorbiditySoftwareVersion3.3 developedaspartoftheHealthcareCostandUtilizationProject (HCUP)bytheAgencyforHealthcareResearchandQuality(2008) [31].

4.3. Performancemeasurement

Weconductedatwo-stepanalysis.First,wemeasuredthe per-formanceindicatorsatthenetworklevelfor2017.Followingthe methodologyoftheTuscanPES[32]foreach indicator,the per-formance of the networks was benchmarked using five-colour evaluationbandsdefinedonthebasisofthepercentiledistribution, wherered(poorperformance)representsthelowestquintileofthe distributionanddarkgreen(excellentperformance)thehighest, sincetherearenointernationalornationalstandardsortargets againstwhichtomeasureperformance.

Secondly, toprovidean effectivegraphical representationof shiftingthefocusfromasingleorganization’sperspectivestothe performanceofnetworksasawhole,wedisplayedtheperformance indicatorsalongthemainphasesofthecarepathway.This illustra-tionfollowsthemethodinNutietal.[15]usinga5-bandevaluation. Thisrepresentationdisplaysthepathways’ performanceatboth primarycareandhospitalnetworkandatAFTlevels,andallows simplerecognitionofthestrengthsandweaknessesofperformance inthedifferentpathwayphases.TheAFTrepresentationenablesthe identificationofintra-AFTvariationintheperformanceofdifferent carenetworks.

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Fig.1.Percentageofpatientswithtwoormoreprescriptionsofbeta-blockerswithinoneyearoftheindexhospitalization.

Fig.2.Percentageofpatientswithatleastonecardiacvisitatoneyearfromtheindexhospitalization.

5. Results

ResultsshowthepresenceofinformalstronglinksbetweenGPs andhospitalbasedonexistingpatternsofpatientflow,whichare notconstrainedgeographically.Inparticular,outof1,965strongGP -hospitallinkages,whichincluded15,841patientswithCHF,linked to1,965GPsand38referencehospitals,wedefined38networks tobeconsideredfortheperformanceevaluationanalysis.About 49%ofCHFpatientsaremale,withanaverageageof81(range, 20–100years).73.5%ofpatientshadatleastonecomorbidityas measuredbytheElixhauserindex(seetheOnlineAppendixforthe dataofeachnetwork).Significantvariabilityincarepracticeand performanceexistamongthenetworksinTuscany(Figs.1,3and2 intheOnlineAppendix).

Onaverage63%ofTuscanypatientshavetwoormore prescrip-tionsforbeta-blockers12monthsposthospitalization(Fig.1).High performingnetworksarethosewithmorethan69%ofpatients beingprescribedbeta-blockers(green).

Fig.2showsthepercentageofpatientswithatleastone car-diac visit within one year of the index hospitalization (range,

28.8%–87.5%).Theregionalmeanis47.9%.Thereishighvariability acrossnetworks.

When looking at outcome indicators, 30-day adjusted mor-talityshowssignificantvariabilityamongthe38networks,from 3.6%–16.8%withaverageregional30-dayadjustedmortalityof11.6 %(Fig.3).

Fig. 4 shows the performance of the care delivered to CHF patientsbythestrong-linkingprofessionalnetworkswith69GPs distributed in16 AFTstoamono-specialty cardiaccentrein an urbanareaofTuscany.Outcomesforthesepatients(n=184)are verygoodwithastatisticallysignificantlower30-daymortality comparedtoaverage30-daymortalityinTuscany.Adherenceto drugtherapyisverygood(e.g.80%ofCHFpatientshavetwoor moreprescriptionsforbeta-blockers12monthspost hospitaliza-tion)aswellasgoodperformanceintheoutpatientfollow-ups,with forinstance,73%ofpatientshavingatleastonecardiacvisitwithin oneyearoftheindexhospitalizationbutwith41%ofpatientswith atleastoneechocardiogram.

Anadditionalfocusisontheprocessandoutcomeperformance ofCHFpatientscaredforbyasingleAFT.TheresultsofFig.5

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high-Fig.3.30dayadjustedmortalityfromtheindexhospitalization.

Fig.4.AnexampleoftheCHFpathwaydisplayingtheperformanceofamono-specialtycardiaccentre(Network28)linkedwith69GPsdistributedin16AFT.

lighttheheterogeneityofreferralbehaviourtospecialistswithin agroupof16GPsworkinginthesameAFT;62.5%haveas refer-encenetworkthenumber10,31.25%Networknumber28andthe remaining6.25%Networknumber20.WecanseethatNetwork 28hasbetterperformancecomparedtoNetwork20andNetwork 10onallprocessandoutcomeindicators,withtheexceptionof 180-dayreadmission.

6. Discussion

Thestudyhighlights theexistenceofinformallinks between GPsand hospitalsbasedonpatternsofpatientflow.These net-workswhich arenot geographicallybasedvaryin theintensity ofrelationshipsandqualityofcare.Suchinformalnetworksmay representthemosteffectiveaccountabilitylevelforchronic dis-easemanagement,sincetheyencompassthemultiplecaresettings experiencedbypatientsandovercomesomeofthelimitationsof formalintegratedcaremodels.

Integratedandcoordinatedcareaimsatbridgingtheboundaries betweenprofessions,providersandinstitutions,andovercoming existing organizational and funding silos. However, the chal-lengesaremultiple,andrequirestrategiesatthemicro,mesoand macrolevels[33,34].Numerousexamplesofmicroandmesolevel approacheshavebeenproposed,suchas,focusingonclinical inte-grationorprofessionalintegration)asmodelsforintegration[35]. However,fewmacrolevelactionintegratedprogramshavebeen putinplace[33].

Froma healthsystemperspective,severalfeaturesshouldbe redesignedtoincentivizeandoptimizeintegration:funding, reg-ulatorymechanisms,managementsystemssuchasperformance evaluationtools,andfinancialandhumanresourcesmanagement systems.Insomehealthcare systems,includingtheItalian,

pro-fessionalslackcommonlydefinedobjectives,informationsystems capable of following the patient across different care settings, andmechanismsofjointaccountabilitytomonitoroutcomesand appropriatenessofcare[11].Someexamplesofhealthgovernance builtaroundteamsofprofessionalsaretheAccountableCare Orga-nizations(ACOs)forMedicarebeneficiariesdevelopedintheUnited States[36],adaptedelsewhereascaregroupsforchronicdisease patients(TheNetherlands)[37].

In some settings with market, quasi-market or social secu-ritysystems, modelsof caresuchas ACOshavebeenproposed. Theseareintendedtoshiftthepricingsystembasedonvolume towardsmechanismstocapturethecontributionofhealth pro-fessionals working together to deliver outcomes and value. In BeveridgesystemswherebothfundingbyDRGforhospital activ-itiesandcapitationfundingforgeneralmedicinearestillfocused oncaresettingsandnotonpatientcare,newperformancetools areneededtoimprovethecontinuityandoutcomesofcare[38]. Intheory,settingsofcaredefinetheboundariesofprofessionals’ actions.However,inreality,thedeliveryofmedicineisshapedby theindependentstatusofprofessionals,andreflectstheirrelative autonomy.

Healthcareprofessionalsarenotrandomlyinvolvedinthecare pathway, but are linked to one another through long-standing relationshipsoftrust,creatinginformalreferralnetworkslinking multi-specialistgroupsofphysicians.Thisleadstothecreationof informalprofessionalnetworksacrosssettings.InthecaseofCHF, patientsareusuallyreferredtothespecialistbytheGP,whotends toestablishconnectionswithateamofspecialistswithwhomthey createaninformal ¨professional_network¨.Improvingthe dynam-icsofinter-professional interactionsisakey issueforachieving importantorganizationaloutcomes,includingthediffusionofbest practice,routines[39]andinnovation[40,41].Thisimpliesthat

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per-Fig.5.AnexampleoftheCHFpathwaydisplayingthenetworkperformanceofoneAFTwith16GPswhohavestrongreferrallinkswiththreedifferentreferralnetworks (GraphA–Network10;GraphB-Network20;GraphC-Network28).

formancemeasuresshouldvaluehorizontalrelationshipsbetween healthcareorganizationsandprofessionals,and mitigate profes-sionalandorganizationalbarrierstonetworking[17,42–45].From this perspective, it is necessary to identifywhich professionals (providers)havebeeninvolvedin thecarepathwayand canbe consideredco-responsiblefortheoutcomes.

Inthislight,ourworkprovidesadata-drivenapproachtofillthe “responsibilitygap”amonghealthcareprofessionals,indeed mea-suringinformalnetworkscanidentifytheprofessionalsinvolved along thecarepathway,and mayenhancecollaboration. More-over,PEStrackingtheresultsachievedbymultispecialtyphysician networkscanimproveperformanceforchronicdiseasepatients through strong primary care, coordinated and integrated care amongGPs,specialists,hospitals,engagementofinterdisciplinary healthprofessionals[46]andfocusonefficiency[47].

ThemainstrengthsofourapproachlieintheselectionofCHF patientsbasedontheprimaryandhospitalcarenetworkandthe identificationofreferralnetworksforreportingqualityand per-formanceencompassingmultiplecaresettings.Suchprimarycare -hospitalnetworksshowedhighaccuracywhenassessedagainst outpatientappointments,confirmingthestrengthoftheidentified networks.Indeed,wefoundthatonaverage,in74%ofthenetworks thereferencehospitalforinpatientserviceswasalsothereference hospitalforoutpatientservices.

Our approach stressestheimportance ofpublicreportingof benchmarkedperformancebyencouragingcompetitionforhigh performance driven by professional reputation [48] and also emphasizes theimportance of clinical engagement to create a learningenvironmentina communityofpracticewhere discus-sion and feedback about performance are conducted. Thus, for effective use of the performance evaluation, provision of feed-backanddiscussionwithprofessionalsis essential[49].Finally, the pathway performance we propose highlights the contribu-tionofeachprovider/professionalindeliveringcareduringeach pathway phase,stressingjointresponsibility intheoverall care pathwayperformance[15].Byadoptingthepathwayperspective, attentionisdirectedtowardthepatient,embracingthevalue cre-ationparadigmwherebyperformancesystemsforcoordinatedcare shouldaimtoincludesystematicassessmentofthepatient experi-ence,thelevelofparticipationinshareddecision-makingbetween patientsandproviders,andself-managementinitiatives[50].

Futureresearchcouldapplythismethodtootherchronic condi-tions(e.g.,complexandmultiplechronicconditions)togeneralize theresults.Moreover,themethodshouldassessandcomparethe utilization of resources among networks.Beyond the PES, new approachesforresourceallocation(e.g.,yearlybudgeting)basedon theneedsofcohortsofchronicdiseasepatientsshouldbe devel-opedatthenetworklevel.

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Thefindingshave somelimitations becauseonly asubgroup oftheCHFpopulationwasassessed;indeed,only“strong” link-agesbetweenGPsandreferencehospitalareconsidered.However, strong linkages are where the locus of responsibilities among settings can be definitively established. Additionally, current administrativedatadoesnotallowtheidentificationofthehospital specialistwhovisitedtheCHFpatientinthereferencehospital,so linkagesof“professionalstoprofessionals”arenotfeasible.Itwill beimportanttoaddthisdimensioninthefuture,aseach profes-sionalplaysakeyroleinthecarepathwayandmayhelpreduce hospitalreadmissionsandincreasetherapeuticcompliance. 7. Conclusions

Howcanperformancemeasurementsystemsholdprimarycare physiciansandspecialistsaccountableforthechronicpatientsthey arejointlyresponsiblefor?Ourcaseprovidessupportingevidence thatan integratedapproach that considersthenaturally occur-ringlinksbetweenprofessionalsworkingindifferentsettingsmay representthemosteffectivelevelofaccountabilityforquality eval-uationofthecareofchronicpatients,byencompassingmultiple caresettingsandthereforecontributingtoefficient,integratedcare andqualityimprovement.

The Tuscan experience in assessing the performance of the heart failure care pathway through the primary and specialist carenetworksrepresentsanexampleofaninter-organizational performanceassessmentsystem,fosteringcollaborativepractices, networkingandsharedresponsibilitybetweenprofessionals, espe-cially in themanagement of carepathwaysfor chronicdisease patients.

Authorcontributions

SabinaNuti:conceptualization,review&editing

FrancescaFerrè:validation,writingoriginaldraft,review& edit-ing

ChiaraSeghieri:methodology,datacuration,validation,review &editing

ElisaForesi:datacuration,formalanalysis ThereseStukel:methodology,review&editing Funding

Theresearchleadingtotheseresultshasreceivedfundingfrom RegioneToscana undergrant agreementNET-2016-02363853-4 (ProjectCARE-NETS)BandodellaRicercafinalizzata2016, Minis-terodellaSalute.

DeclarationofCompetingInterest

Theauthorsdeclarethattheyhavenoconflictsofinterest. Acknowledgements

This study was supported by the regional administration -Direzione Dirittidi cittadinanzaecoesionesociale- ofRegione Toscana. We thank Professor Michele Emdin, Scuola Superiore Sant’Anna, for his clinical competence in interpreting the data on heart failure and the profitable discussions throughout the researchproject.Theauthorsareparticularlygratefultothework ofGiusepped’Orio,LaboratorioManagementeSanità,fortheearly adaptationoftheOntariomultispecialtyphysiciannetworkmodel toTRHSandhisconstanthelpduringdataprocessing.

AppendixA. Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,in theonlineversion,atdoi:https://doi.org/10.1016/j.healthpol.2019. 11.001.

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