Programme 1: characterization of chronicity and assessment of healthcare performance and health policy strategies in chronic care

WP1: Burden associated to chronic diseases

(Responsible Dra. Alexandra Prados)

• Assessing and monitoring the health status, evolution, services utilization, and costs of the population with highly prevalent chronic conditions (such as Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Osteoarthritis and Osteoporosis (O&O), Colorectal Cancer (CC) or Breast Cancer (BC)), and characterization of multimorbidity and frailty.b) Identifying and assessing the role of key determinants of risk with impact in health outcomes and services utilization, particularly describing the profile of multimorbid and frailty patients, and investigating the determinants of disease progression.
• Characterizing patients’ perspective eliciting self-perceived health and associated utilities, preferences or critical factors to be considered in their empowerment.

WP2: Health systems in response of chronicity

(Responsible Dra. Mireia Espallargues)

• Identifying and monitoring unwarranted variations in chronic care performance, in particular, in equity in access, quality and safety, and efficiency.
•  Assessing and monitoring appropriate utilization of services, medical and surgical diagnostic and healthcare procedures and drugs, with specific emphasis on multimorbid patients and polypharmacy.
•  Assessing and monitoring continuity of care, in particular treatment continuation.
• Characterizing and assessing organizations and policies developed to deal with chronic care, in particular, those considering the use of ICTs.

WP3: Methods for data management, analysis and reporting

(Responsible Dra. Berta Ibáñez)

• Implementing data quality analyses using big data approaches for the management of databases and the creation of cohorts, particularly when using real world data.
• Development of prediction rules, risk stratification methods and simulation techniques to model events.
• Design and validation of tools to consider the patient’s perspective (utilities, preferences, PROMS and empowerment)
• Design and validation of performance indicators and PROMS, performance evaluation and benchmarking, evaluation of appropriate use, and adaptation of methods to evaluate costs, budgetary impact and efficiency in the distribution of resources.