Group leader: Itziar Vergara Micheltorena, Ph.D.

Donostialdea IHO itziar.vergaramitxeltorena@osakidetza.eus

Objectives and lines

The Basque Public Health Service has a primary care network which constitutes the entrance door to the health system for citizens and represents one of its greatest strengths in regard to accessibility and the ability to solve most of the population’s health problems. The service provides integrating and continuous care, both necessary conditions for effectively and efficiently caring for chronicity.

The added value of the Primary Care (PC) research integrated to the new IHO structures is determined by a series of factors typical of this area of care: Patient-focused care and holistic focus; Competences in solving clinical problems; Integral focus; Management of primary health care and Community orientation.

The very nature of the sphere represented in this proposal establishes its scope and its variety. The possible research lines are countless and, given the experience and quality of professionals in the region of Gipuzkoa, the work proposal of this group is broad and varied.

These are the main lines of work and their associated objectives:

Line 1: Integral approach to patients with chronic diseases

Our organisation’s model change must address the best way to provide health care to patients with chronic diseases and different degrees of complexity. This means generating knowledge on the most efficient way to proceed.

Disease self-management and patient enablement

• Study of the possibilities of introducing programmes for the self-management of chronic disease in our environment
• Design studies to analyse the effectiveness of disease self-management
• Identify elements of success in disease self-management programmes

Adjustment of pharmacological treatment, of preventive strategies and of risk factor control

• Place priority on recommendations based on evidence of preventive strategies, risk factor control and the adjustment of pharmacological treatment in elderly patients and/or those with multimorbility
• Identify avoidable iatrogenic effects associated to the more frequent treatments in elderly patients and/or those with multimorbility and place priority on the main problems
• Design interventions to implement priority recommendations in regard to preventive strategies, adjustment of treatment and avoidable iatrogenic effects in the context of the integrated organisations
• Evaluate the impact of interventions in normal clinical practice conditions

Integral approach to fragility

• Design appropriate instruments for their use in PC-OHIs with a view to identifying fragile subjects
• Analyse the determining factors of fragility
• Design interventions to reverse fragility

Line 2: PC strategies and diagnostic tests: validation and analysis of their adjustment

• Identify appropriate diagnostic tests for their application in PC and adapt them to the PC environment
• Develop, validate and evaluate the applicability of CPR in the PC environment