El reto de la cronicidad en Euskadi: el proyecto de estratificación poblacional

Introduction: Chronic diseases pose an increasing threat to people's health and quality of life. The 'Strategy for tackling the challenge of chronicity in the Basque Country' was designed to transform the healthcare delivery model, adapting it to the new epidemiological context. Among its policies proposes a stratified and prospective assistance, suited to the care needs of the patients according to their morbidity level. In 2010 began in the Basque Country the implementation of a stratification system that includes clinical and social variables, as well as data about prior use of services. Methods: We collected data from a 12 month period (from 01/09/2009 to 31/08/2010) of every patient assigned to Osakidetza during a minimum of 6 months (n = 2,252,981). The sources of information were medical records of primary care (demographic variables, diagnoses and prescribed drugs) and administrative data from hospital discharges (number of admissions, diagnoses and inpatient procedures). Using the Johns Hopkins Adjusted Clinical Groups Predictive Model (ACG-PM) the patients were classified depending on their diseases. For each person, a prospective estimate of the healthcare cost of the following year was obtained. Results: The information provided by the case-mix allows the identification of patients suffering from certain health problems and with a specific risk level in the coming year. On that basis, we selected target populations for interventions that are being developed in Osakidetza. Conclusions: The adoption of a population approach gives guidance on how to direct our effort to improve patient care and contribute to the efficiency of the health system.