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High-grade meningiomas are associated with neuro-cognitive morbidity and have limited treatments. High-grade meningiomas harbor an immunosuppressive tumor microenvironment (TME) and programmed death-ligand 1 (PD-L1) expression may contribute to their aggressive phenotype. Here, we present the results of a single-arm, open-label phase 2 trial (NCT03279692) evaluating the efficacy of pembrolizumab, a PD-1 inhibitor, in a cohort of 25 evaluable patients with recurrent and progressive grade 2 and 3 meningiomas. The primary endpoint is the proportion of patients alive and progression-free at 6 months (PFS-6). Secondary endpoints include progression-free and overall survival, best intracranial response, and toxicity. Our study has met its primary endpoint and achieved a PFS-6 rate of 0.48 (90% exact CI: 0.31–0.66) and a median PFS of 7.6 months (90% CI: 3.4–12.9 months). Twenty percent of patients have experienced one (or more) grade-3 or higher treatment-related adverse events. These results suggest that pembrolizumab exerts promising efficacy on a subset of these tumors. Further studies are needed to identify the biological facets within the meningioma TME that may drive response to immune-based therapies.

To face the challenge of active and healthy ageing (AHA), European Health Systems and services should move towards proactive, anticipatory and integrated care. Health care systems thus need to personalize services, put patients at the centre of care and provide services using the adequate resources. Population health risk management is emphasized through the use of tools to stratify people with chronic diseases according to their risk. Effective screening of frailty is vital for optimizing the care of frail populations at risk. The Activation of Stratification Strategies and Results of the interventions on frail patients of Healthcare Services (ASSEHS) EU project (N° 2013 12 04) is an international effort whose aim is to bring together stratification-related professionals from Health Services, Academia and Research in the EU in order to (i) study current existing health risk stratification strategies and tools, (ii) spread their use and application on frail elderly patients, (iii) minimize deterioration of conditions and/or (iv) prevent emergency or hospital admissions. The analysis of Risk Stratification in different Health Systems will generate conclusions and risk stratification solutions, which will be transferable to a variety of regions in the future. ASSEHS is in line with Area 4 of the B3 Action Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA).

Introduction : Population aging and the increased number of chronic diseases push the healthcare systems to design and implement new strategies to improve the quality of services. These strategies require investment in ICT tools, promotion of patient empowerment in the management of their disease and a better integration of health and social care services. CareWell project focuses on the delivery of integrated healthcare to frail elderly patients who have complex health and social care needs, are at high risk of hospital or care home admission and require a range of high-level interventions due to their frailty and multiple chronic diseases. Carewell aims at deploying services supported by ICT which enhance the coordination and communication of healthcare professionals, improves patient´s remote follow up and boosts patient (and caregiver) empowerment. The aim of the project is the identification of the impact of implementing an integrated care model for frail elderly patients, according to quality of care, efficiency and both patients´ and professionals´ satisfaction. Short description of the intervention : Following the inclusion criteria and based on the population stratification dataset, the GP identifies potential candidates. Then, the GP proceeds to schedule a consultation with the patient to perform a comprehensive assessment, define the therapeutic plan and provide patient with educational material in order increase his/her self-management capability. Then, the GP nurse schedules a face-to-face follow-up plan depending on the patient's needs. During this face-to-face consultation, the GP nurse analyses patient's therapeutic plan and his/her adherence to treatment, reinforces patient's self-management capacity through an educational plan, revises lab tests and performs medical examinations. If no worsening symptoms are detected, the patient is reviewed approximately every three months. However, if any instability sign is identified, the patient is referred to the GP in order to reassess his/her clinical situation. If the patient can benefit from home care, a variety of resources can be activated. If the patient cannot be treated at home, or his/her health status continues to worsen, the patient will be admitted to hospital. During the hospitalisation, the reference internist is in charge of assessing the patient's clinical situation, defining corresponding treatment, managing medical interventions and coordinating specialists. Once the patient is stable, the reference internist will consider if the patient requires additional interventions such as home-hospitalisation, admission to a sub-acute hospital, social care, or special coordination with primary care. At hospital discharge, the reference internist writes the discharge letter and contacts the GP to ensure continuity of care. In addition, the hospital nurse draws up the patient's follow-up plan, and schedules a face-to-face appointment between the patient and the GP nurse. The visit with the GP nurse is the starting point of the integrated care pathway, from where the patient can be referred to periodic follow-up consultations or to hospital, depending on his/her health status. Key findings: The definition of the care pathway supported by ICTs has been deeply discussed in an inter-organizational and multidisciplinary work group (managers, clinicians nursing of primary care and hospitals, eHealth Centre, Department of Information Systems, Department of Healthcare and Kronikgune), ensuring that all stakeholders´ opinions and needs are considered. 200 patients (100 intervention group and 100 control group) have been recruited and the services aforementioned are fully operational. At this moment the enrolment data is being collected and the baseline analysis (quantitative and qualitative indicators) will be performed during December. In addition, predictive modeling approach will be carried out to estimate the use of resources in mid- and long-term after the new service deployment. Highlights and conclusions : Intervention perspective: - Need of a clear methodology to design the intervention (analysis of current model, detection of improvement areas, prioritize actions and define the new care pathway) - Need of resource re-organization and definition of new roles to improve coordination between different healthcare levels (primary and secondary care). - Primary Care is responsible for proactive control of the patients. - Patient and informal caregiver empowerment leaded by nursing is essential. - Technology is crucial to facilitate coordination between healthcare professionals. Implementation perspective: - Need to align the objectives of the project with the strategic plan of the central organization so the deployment of the service becomes a priority. - Importance of reach consensus among all stakeholders in the definition of the care pathways in order to consider different perspectives (managerial, technical and methodological competences). - Ensure the service is adaptable and flexible enough to be adopted in new contexts. - Distributed leadership is crucial from the implementation process perspective (clinical, managerial and methodological) - Need to share midterm results and collect feedback from front-line professionals to detect improvement areas

Introduction : Around 50% of those suffering a depression do not receive treatment and this is due to barriers such as lack of resources for mental health care or stigma related to mental disorders. Research shows that some of these barriers can be successfully overcome with ICT-based solutions among which Computerized Cognitive Behavioral Therapy (cCBT) has proven to be an effective and cost effective treatment for depression. Unfortunately the use of these ICT is still anecdotal in most regions and little is known about the potential health and economic impact of its generalization. Mastermind project is an EC co-funded project involving 23 partners of 11 European countries. Mastermind pretends to up-scale cCBT based interventions across distinct European regions and study the barriers and facilitators of the implementation process. In addition, a comprehensive evaluation process has been set up to study quantitative and qualitative indicators framed into seven domains: health problem, safety, clinical effectiveness, organizational aspects, economic aspects, patients perspective, socio/legal/ethical aspects. In the Basque Country 300 patients will participate in the cCBT intervention. Short description of the intervention : The integrated care based intervention deployed in the Basque Country aims to give a major role to the primary care professionals in the provision of care for patients with depression. The GP and GP practice nurse are responsible for identifying and recruiting patient fulfilling the inclusion criteria defined (>18 years with mild or moderate depression diagnosed by the Patient Health Questionnaire-9). Once the patient accepts to participate in the project, the primary care team trains him/her in the use of the cCBT programme and provides him/her with the required username and password. During the online therapy, the patient has to fill different health related questionnaires (PHQ-9, BDI, Euroqol and MANSA-2) and go through 8 educational modules. Each module contains three sections: explanatory text, summary presentation and a video. The patient is supposed to read the text, revise the presentation and listen to the video in order to internalize the content of the session. Afterwards, the patient fills some specific exercises that are reviewed by the GP. During the online therapy, the primary care team are in charge of monitoring the progress of the patient and are supported by the nursing of the eHealth Centre, who work 24x7, in several tasks: phone calls to reinforce the adherence to the treatment, follow-up calls and activation of health resources depending on the final scores of the questionnaires (schedule an appointment in the GP office or specialist, activation of the ambulance). During the cCBT, the specialists (psychiatrists and psychologists) support the GPs in any decision-making when necessary. To do so, the GP solves clinical doubts via intercolsultations (messages via the EHR) or or via videoconference. Key findings : - The cCT programme has been collaboratively developed by the 4 Spanish regions within the project (Aragon, Galicia, Badalona and Basque Country) based on the existing scientific evidence. The programme has been adapted to their local requirements (language, culture and health care characteristics). - The four Spanish regions are deploying a similar organizational model in order to demonstrate the validity of both the online programme and the integrated care intervention. - Primary care professionals have to manage patients with mild and moderate depression, limiting the participation of the specialists to the most complex cases and severe depression. By this way, the waiting lists will be reduced in the mental health centers and primary care professionals are provided with a effective tool to improve their decision making. - Intense dissemination and sensitization efforts have been done to maximize the interest of health professionals and patients in the use of ICT resources as part of depression treatment. Highlights: (lessons learned) - Definition of the cCBT programme based on the requirements of both patient and professionals profile. - Need to reinforce the knowledge of primary care professionals in the clinicnal management of the depression. - Integration between distinct healthcare professionals (GP, GP practice nurse, specialists and eHealth Centre) is crucial to ensure an integrated care for patients with depression. - The duration of the online therapy has to be limited (eg. 12 weeks) in order ensure the engagement of the patient and guarantee the effectiveness of the therapy. Conclusions : The cCBT will be deployed in distinct regions trying to identify barriers and facilitators of the implementation process. The knowledge generated will be of paramount importance for future extensions of this type of care in a safe, efficient and effective way.

Objectives To develop a framework for the management of complex health care interventions within the Deming continuous improvement cycle and to test the framework in the case of an integrated intervention for multimorbid patients in the Basque Country within the CareWell project. Methods Statistical analysis alone, although necessary, may not always represent the practical significance of the intervention. Thus, to ascertain the true economic impact of the intervention, the statistical results can be integrated into the budget impact analysis. The intervention of the case study consisted of a comprehensive approach that integrated new provider roles and new technological infrastructure for multimorbid patients, with the aim of reducing patient decompensations by 10% over 5 years. The study period was 2012 to 2020. Results Given the aging of the general population, the conventional scenario predicts an increase of 21% in the health care budget for care of multimorbid patients during the study period. With a successful intervention, this figure should drop to 18%. The statistical analysis, however, showed no significant differences in costs either in primary care or in hospital care between 2012 and 2014. The real costs in 2014 were by far closer to those in the conventional scenario than to the reductions expected in the objective scenario. The present implementation should be reappraised, because the present expenditure did not move closer to the objective budget. Conclusions This work demonstrates the capacity of budget impact analysis to enhance the implementation of complex interventions. Its integration in the context of the continuous improvement cycle is transferable to other contexts in which implementation depth and time are important.

Background: Health risk assessment and stratification have proven highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. Aim: The principal objective was to analyse five health-risk assessment strategies used in the five regions participating in the Advancing Care Coordination and TeleHealth Deployment (ACT) program (www.act-programme.eu): Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). A second aim was to explore the potential of population-based health risk predictive tools to contribute to risk prediction in the clinical setting. Method: We characterized and compared risk assessment strategies among ACT regions by analysing operational risk predictive modelling tools for population-based stratification, as well as available health indicators. The risk assessment tool deployed in Catalonia (GMA, Adjusted Morbidity Groups) was used as an example to explore how population-based analysis can contribute to clinical risk prediction. Results: The study indicated a high degree of conceptual agreement among the five ACT regions on the relevant role of population-based health risk assessment for regional deployment of integrated care. The entire ACT consortium shared its usefulness for service commission, case finding and screening. There was also consensus on the use of a population health approach as the optimal strategy for population-based risk assessment. However, the health risk predictive modelling tools in place displayed marked heterogeneities that precluded comparability of the risk pyramid distributions across regions. We identified a clear need for evolving toward risk predictive modelling tools allowing proper quantification of the estimations. Likewise, different well-identified problems mostly associated to data reporting precluded appropriate comparisons of the recommended health indicators. The current study identified transferability across regions and potential for evolving, that is flexibility, as two key requirements for any population-based health risk assessment tool. Factors such as: i) license binding constraints, ii) insufficient public availability; iii) lack of availability for inspection; and/or, iv) rigidity of some computational algorithms (i.e. due to inclusion of expert-based criteria in some morbidity groupers) are currently limiting transferability. These factors might also preclude adaptation of the current risk prediction tools toward evolving requirements such as: i) integration between healthcare and social services; and, ii) implementation of synergies between population-based and clinically oriented risk predictive modelling, as described in the study. We acknowledge some intrinsic limitations of population-based predictive modelling in terms of strength of estimations. However, their potential for allocation of individuals into the risk stratification pyramid facilitates both design and implementation of preventive strategies that have shown high potential to generate healthcare value. Moreover, the study reports on the conceptual steps required for development of innovative strategies for clinical risk predictive modelling with potential to enhance its supporting role for decision making in the clinical scenario. Conclusions : We acknowledge that further efforts should be devoted to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. The novel strategy for enhanced clinical risk assessment requires prospective evaluation.

Introduction: Congestive Heart Failure (CHF) is a complex syndrome characterized by the inability of the heart to expel sufficient amount of blood needed for metabolic requirements of different organs. As a result, the typical symptoms affecting patient with CHF are dyspnea and fatigue at rest or with reduced physical effort, and loss of appetite, which sometimes appear gradually over days or weeks. Epidemiological studies indicate that the prevalence of CHF is considerably high affecting 10% of the population older than 70 years old. Due to the population ageing and the increased survival to acute cardiac diseases, CHF is becoming more common, representing a public health problem. In consequence, it will become increasingly difficult to maintain the quality of care of patient suffering from CHF. In this context, home telemonitoring appears to be a promising alternative to allow healthcare professionals to follow up patient s health status more closely and then facilitating early detection of worsening symptoms. However, the effectiveness of these interventions in real conditions has not yet been sufficiently tested, since the implementation of telemonitoring services is considerably complex. Frequently telemonitoring studies do not overcome the pilot phase and do not reach the expected success when it comes to scale and place the intervention in routine practice. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117013 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Aim: Define and implement cost-effective and sustainable telemonitoring services for patients with CHF within an integrated care model where each actor performs the task more suited to his/her position in the value chain. Timeline: 300 patients will be recruited from May 2014 to January 2015 and each patient will be followed up during 12 months. Methodology: Definition of crucial aspects of the telemonitoring intervention has been deeply discussed in an inter-organizational and multidisciplinary work group, reaching consensus on how to implement the services within an integrated organizational model. The working group is composed by: managers (primary care and hospitals), cardiologists, general practitioners, nursing (from primary care, hospital and eHealth Center), Telecare Centre’s director and staff from the Department of information systems. The indicators that will be measured consider health outcomes, patient s quality of life, economic and organizational aspects, patient s perception, and ethical-legal-cultural aspects. Short description of practice change implemented: The patient who meets the inclusion criteria and signs the informed consent will be enrolled in the intervention. The technical provider will be responsible for installing devices for the measurement of the heart rate, blood pressure, pulseoxymetry and weight at patient's home within a week after recruitment. In addition, a personal alarm device for 24/7 real-time emergency detection will be installed. The patient will be trained in using the telemonitoring and telecare devices. Following the clinician's prescription, the patient will routinely transmit his/her parameters at least once per week. The telemonitoring devices collect and send the data wirelessly to the gateway located at his/her home. The gateway device transmits the data collected by the patient to the alarm management system of the _Telecare Centre_. The operator of the Telecare Centre checks the data sent by the patient and activates the predefined protocol agreed by a group of professionals, including clinicians, general practitioners, nurses, general directors and representatives of the social area. When clinical parameters are out of range, the operator first verifies the alarm situation by a phone call to the patient. If the alarm is validated, the operator triggers the protocol depending on the severity of the situation. The operator contacts the _eHealth Centre_ composed of nurses; they then solve the alarm on their own, notify the _general practitione_ or the _specialist_, or activate _Emergency Department_. If the patient uses the 24/7 real-time alarm device provided, the Telecare Centre's operator can contact the Emergency Department and/or social services. In addition, the Telecare Centre also solves any technical problems arising in the use of devices. Conclusions and lessons learned: The conclusions reached at this point of the project are: Need of resource re-organization and definition of new roles. The organizational model using telemonitoring services model has to be well adapted to the routine practice. Complete telemonitoring service has to be provided (device installation, maintenance and user training) Need of both administrative management and guarantee of good quality of telemonitored data (avoiding false alarms). Patient empowerment leaded by nursing is essential. Primary Care is responsible for proactive control of the patients Technology is crucial to facilitate both coordinated management of all processes and communication between healthcare professionals. Healthcare professionals do not have to deal with different technological platforms; they should work on the Electronic Health Record of each patient.

Introduction: Population health management strategies can be improved through the use of Risk Stratification (RS) tools. Moreover, RS tools serve to support integrated interventions targeted for specific groups of patients. Integrated interventions are especially relevant for frail patients since they can improve patient’s wellbeing and in parallel, increase healthcare-system sustainability. Thus, effective screening of frailty is crucial in optimizing care for frail population. RS tools identify high-risk patients and help ensure appropriate coverage of key secondary prevention interventions, including managing disease registers systematically by modelling expected versus actual risks, and thereby identifying practices where care integration is more necessary. However, current risk stratification strategies and tools have not been widely deployed and their ability to predict adverse events is unknown. Challenges to spread their use include tools’ availability and usability, but also data requirements and accessibility, adaptation to real life services and clinical practice circumstances, clinicians’ acceptance or barriers related to healthcare structures and processes. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117023 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 ASSEHS project analyses stratification strategies used in different Health Systems over Europe and the lessons learnt out of their implementation, identifying (amongst other outcomes) barriers, facilitators and impact that the introduction of RS tools has on Health Services. Methodology: ASSEHS project comprises 4 Core Work Packages. WP4, 5 and 6 focus on the analysis of; a) risk stratification tools, b) feasibility of the introduction of risk stratification tools in health services and c) impact of the introduction on the utilization of risk stratification tools, respectively. WP7 focuses on the evaluation of the interventions done in different Health Services of Europe and is supported by the findings of the analysis work packages. The present communication is focused on the analysis of the feasibility of including stratification tools in the health systems (WP5) and its impact (WP6). Work builds on a scoping review that serves three different purposes; 1) collecting documents on risk stratification, 2) detecting interventions where risk stratification has been used and 3) identifying names and contact details of Key Informants. In addition, qualitative questionnaires have been deployed between Clinicians, Healthcare Managers, Healthcare Planners, Commissioners, Developers-Subcontractors, Operators involved in the management, processing and evaluation of the data and Technology providers from different settings; Primary care, Specialized care, Social care, Prevention and Planning service...). Only the persons that have been actively involved in the design and/or implementation of risk stratification were eligible to respond this questionnaire, this is why it is targeted to key informants in each region. Qualitative questionnaires have been designed to identify barriers and facilitators based on real life implementation experiences of risk stratification tools in 4 regions in Europe (Lombardi, Catalonia, Puglia and the Basque Country). Results: The scoping literature search resulted in 984 documents, which were filtered by at least by two persons each. 73 documents were selected, and underwent an analysis using a decision tree. From this analysis, 13 documents were selected for critical lecture. The literature search was completed with a snowball type of search identifying 30 documents, from which 9 were selected for critical lecture. The primary output from the literature review was a feasibility analysis of 9 areas: Information Systems and technology, Operational, Technical, Human Resources, Schedule, Financial, Legal, Economic and Others. Regarding each one of the areas above, barriers and facilitators described in the selected documents were identified and described in a report. The analysis of the qualitative questionnaires identified 4 areas as critical in the implementation process of the RS tools; training of end users, communication of the implementation process, integration of the tool on ICTs and ability of tools to identify patients to be selected for interventions. Conclusions: The study done in WP5 of ASSEHS will help fine tune the stratification implementation experiences in 4 European regions. The analysis of Stratification techniques in different Health Systems and the lessons learnt out of the evaluation of interventions implemented on four Health Services under the umbrella of ASSEHS, will generate useful conclusions and solutions transferable to a variety of regions in the near future.

Introduction: Population aging and the increased number of chronic diseases push the healthcare systems to design and implement new strategies to improve the quality of services. These strategies require investment in ICT tools, promotion of patient empowerment in the management of their disease and a better integration of health and social care services. CareWell project will enable the delivery of integrated healthcare to frail elderly patients in a pilot setting through comprehensive multidisciplinary and tightly knit programmes. ICTs will play a major role in the coordination and communication of healthcare professionals and of patient centred delivery of care at home. CareWell will predominantly focus on the provision of care and support to older people who have complex health and social care needs, are at high risk of hospital or care home admission and require a range of high-level interventions due to their frailty and multiple chronic diseases. This will be achieved through ICT enabled health and social care services coordination, monitoring, patients self-management and informal care givers involvement. The ICT platforms and communication channels will avoid duplication of effort when dealing with patients‘ diagnostic, therapeutic, rehabilitation or monitoring and support needs. Additionally, ICT-based 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117014 – http://www.ijic.org/ platforms can improve treatment compliance, enhance self-care and self-management and increase patient and carer awareness on their health status. All of which will improve clinical outcomes and enable people to lead fulfilled lives. Moreover technologies will support the patients’ informal caregivers highlighting when respite care or additional professional input is required. Aim: Identification of the impact of implementing an integrated care model for frail elderly patients, according to quality of care, efficiency and bot patients and professionals satisfaction. Timeline: 100 patients will be recruited from February 2015 to June 2015 and each patient will be followed up during 12 months. Methodology: Definition of crucial aspects of the intervention has been deeply discussed in an inter-organizational and multidisciplinary work group, reaching consensus on how to implement the services within an integrated organizational model. The working group is composed by: managers (primary care and hospitals), professionals of internal medicine, general practitioners, nursing (from primary care, hospital and eHealth Center), Telecare Centre’s director and staff from the Department of information systems. Highlights: This group has defined the characteristics of the target population, the organizational model, the integrated care pathway to be implemented, as well as the functionalities required with respect to the corporative ICT tools (Electronic Health Record, electronic prescription, Personal Health Folder, web portal). Conclusions: The conclusions reached at this point of the project are: Importance of reach consensus among all stakeholders in the definition of the care pathways in order to consider different perspectives and integrate them in the intervention. Need of resource re-organization and definition of new roles to improve coordination between different healthcare levels (primary and secondary care). Primary Care is responsible for proactive control of the patients. Patient and informal caregiver empowerment leaded by nursing is essential. Technology is crucial to facilitate both coordinated management of all processes and communication between healthcare professionals. Healthcare professionals do not have to deal with different technological platforms; they should work on the Electronic Health Record of each patient.

Introduction: Bipolar disorder is a disease that causes changes in the regulation of mood, varies from deep depression to more uncontrolled euphoria without external events that justify these variations. Bipolar dissorder affects 2-5% of the population, with similar prevalence among men and women without differences of race or social class, and usually arise between 20-30 years old. The cause are varied and can be genetic, and therefore inheritable, but enviromental factors (stress, drug use...) that make emerge the disorder are required. Short description of practice change implemented: The usual treatment is based not only in drug therapy but also in educational programs such as psycho-education programs to provide information to patients and family about the disease and negative habits, help to know the symptoms of destabilization and establishing routines, teach to cope with the stress and the importance of taking proper medication. However, the therapies on line are becoming more frequent with the technological advances. These therapies offers advantages compared to the usual treatment as: facilitate access to therapy (not displacement and possibility to adjust schedules), the anonymity is guarantee... A new approach for online treatment has been development, the Bipolar Patient Treatment Manager (BPTM) solution which provides telecare service based on advanced communication channels to treat, monitor and support people with mental disorders and their relatives. A rigorous analysis of various online treatments has been done in order to design an application which 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117110– http://www.ijic.org/ satisfies all the relevant features: appropiate educational programs, enviroment friendliness, multichannel interaction, security in the exchange of information... Targeted population and stakeholders: The targeted population for the BPTM solution are patients with bipolar disorder, their carers and the professionals involved in their care and treatment (primary and specialized level). Timeline: A clinical trial will performed in May, 2015 with a duration of three months. The clinical trial will consist on the comparation of two patient and carer groups (intervention and control): 30 patients and their carers using the BPTM solution (intervention group) and 30 patients and their carers with usual treatment (control group). The profesional teams involve agents from primary and specialized care of the Basque Health System (Osakidetza). Highlights: (innovation, impact and outcomes) The designed application (BPTM) has been development and consists on the following modules: psycoeducation, psycotherapy, health state monitoring, drug treatment adherence. The solution is being developed to allow secure multi-channel interaction between patients and health care professionals, to ensure safely information exchanged which allow to integrate the clinical relevant information within the existing electronic health record by interoperating with existing infrastructures trough standards. Conclusions: The BPTM solution will offer ways to learn about how to manage the disease and how to identify symptoms and risk or unstable clinical situations; means to register, share, and access relevant quantitative and qualitative status information, drugs intake, and potentially unwanted side effects; feedback relevant for psychotherapy (i.e. information to the patient about the evolution of his/her disease, motivational messages, and comments of his/her therapist). Discussions: The expected results of the online treatment are basically focused on improving health outcomes and efficiency, increasing the population treated and the adhesion to the treatment, avoiding readmissions and optimizing the resources used. The cost-effectiveness and the transferibility of the application will be evaluated Lessons learned: Some our lessons learned in the development of the online application are related to the need of adaptation of the application to the user requierement. These user requirements involved several areas as the content in the application depending on targeted population, an active and attractive application with an easy handling in order to assure the patients treatment adherance, but also confidentiality, security, privacity and tracebility to be sure that the application has been used by the adequate person.

Background: Predictive risk modeling elaborated from large population-based datasets using citizens traits, including historical information on use of healthcare resources, as potential predictors have shown to be useful mainly for two purposes: (i) to design health policies, with a preventive approach, in a given geographical area; and, (ii) to identify individuals with high risk for presenting undesirable health events (case finding) such as hospital admissions, functional decline and/or death. The ACT (Advancing Care Coordination and Telehealth deployment) programme is fully aligned with the European Innovation Partnership on Active and Healthy Aging (EIP on AHA)

Introduction: Depression is one of the most frequent mental health diseases worldwide, with aproximately 350 million of individuals affected. Nevertheless, over 50% of them do not receive an adequate treatment. Lack of resources and mental health illness' stigma are among the barriers to it. On the other hand, lack of accessibility and mental health services' waiting lists contribute to this situation. Computerised Cognitive Behavioural Therapy (cCBT) has proven to be effective to fight depression, enabling the patient to change destructive patterns. This type of cCBT can be selfadministrated at any time and place; this is why it contributes to improve accessibility to treatment. Also, it enables the delivery of care at the natural environment, minimizing the negative effect of mental health stigma, and contributing to the acceptance of the one's own condition. The main objective of this project is to deploy a cCBT solution, within an integrated care intervention, as well as to identify and analyze the barriers and facilitators of this process, both in the clinical and organizational fields. Short description of practice change implemented: The practice being implemented comprises two main work areas: 1. Development of a cCBT platform, taking into account the needs for patient-professional interaction and fluid communication, integration within information systems and therapeutic content that nurtures the platform. The integration of the plataform will be finished in January 2015. 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117109– http://www.ijic.org/ 2. Put into practice an integrated care intervention targeting 300 individuals over the age of 18, diagnosed of depression according to DSM IV, and recruited in mental health care centres, primary care centres and hospitals. This intervention will begin the September 2015. The patients will be treated for 12 months and their status will be evaluated at the baseline, in the middle of the treatment, at the end of the treatment and three months after the end of the intervention. The assessment of the professionals and organizations involved will be carried out at the end of the treatment. Highlights: The cCBT platform enables a two-way patient-professional communication. On the other hand, the architecture of the platform enables a close follow-up, while providing the patient with tools to manage its own condition and prevent future episodes. Regarding the deployment of the intervention, scalability of the model to the health system, transferability to other health systems, decrease of adverse events and health outcomes, costeffectiveness, inequities and waiting lists evolution will be measured. For this, the results will be analyzed at three levels: patients (control group and intervention group), professionals (primary care and mental health) and health services organizations. Conclusions: This project is expected to raise awareness about the key issues underpinning online cCBT integration within regular care, generating the knowledge and expertise needed for the extension of this type of care in a safe, efficient and effective way.

Introduction and Aim: the new model on financing and contracting (NMFC) of the Basque Health Service (BHS) aims to align and lead the health providing organizations towards the creation of local integrated health systems (LIHS). As such, a LIHS should show: coordination with shared responsibility, strategic objectives according to population risk stratification, improvements in care and health outcomes, and generation of efficiencies. Such proposal aims to provide sustainability to the health system and act as a spurring element for the BHS, given that parts of the generated efficiencies revert into the organization. Material and Methods: Grouping of the health organizations in LIHS according to their population. Definition of the NMFC: linking the 3% of the financing of the BHS to every LIHS (primary care, acute and subacute care hospital), to population interventional plans (PIPs, 0.5%), quality (0.5%) and innovation (0.5%). Definition of PIPs prioritizing most prevalent pathologies and those in need of greater coordination between assistance levels. Use of the stratification tool for the selection of the groups to be intervened proactively. Results: 44 PIPs were displayed, 4 per LIHS (target population): pluripathology (3575), COPD (5294), HF (3699) and Diabetes (10984). An evaluation frame and assessment guidelines were deployed for each intervention and committed resources were distributed for the Intervention Plan. International Journal of Integrated Care – Volume 13, 11 October – URN:NBN:NL:UI:10-1-114680– http://www.ijic.org/ 13 th international Conference on Integrated Care, Berlin, Germany, April 11-12, 2013 2 International Journal of Integrated Care – Volume 13, 23 October – URN:NBN:NL:UI:10-1-114680– http://www.ijic.org/ Discussion: The NMFC implies a series of changes: from specific individual objectives to shared objectives in the same LIHS, from a reactive to a proactive medicine, from activity related payment to measure the results in health, from a generalized attention to an adapted attention depending on the necessity and morbidity of the patients. The change in the model introduces and important change in the work mode and management, i.e, a switch from structure based work to system based work.

Introduction: Local Integrated Health Systems In the Basque country and elsewhere, a necessity of change regarding the management of the national health system has been identified. The current structure centered model needs to evolve to local integrated health systems (LIHS), able to provide continuity of care, be proactive and empower patients. A transformation of system-wide delivery was made in the Basque Country, promoting and planning the local innovation process. Methods: Planning the Innovation The following actions were taken during the planning phase: a) reserve of a bottom up innovation space in the funding system, defining subject and objectives, b) reserve of time for the LIHS to develop experiences and care provision organizational models for pluripathology (PP) patients, c) Collaborative sessions, d) identification of key elements and success factors and e) elevation to Population Interventional Plans (PIPs). Results: Deployment Process The deployment process consisted in the following steps, (which used the above methodology): 1) Promotion of Bottom Up (BU) experiences 2) Identification of interventions targeted to homogeneous groups and sharing common objectives: in 2010, 6 LIHS had developed new ways of intervention on PP patients and by 2011, this number was elevated to 8. 3) BU project analysis focusing on organizational and personnel related key elements. 4) Elevation to PIPs: selection of specific population using population stratification tool, design of a care pathway, coordination and communication tools, and evaluation framework. 5) PIPs deployment: in 2012, PIPs were displayed all over the Basque Health Service, subjected to continuous benchmarking (e.g analysis of the detected needs, continuous improvement, adaptation and anticipation of the macro system to the necessities of the LIHS).

Introduction : The prevalence of congestive heart failure is considerably high affecting 10% of the population older than 70 years old. Due to the population ageing and the increased survival to acute cardiac diseases, CHF is becoming more common, representing a public health problem. In consequence, it will become increasingly difficult to maintain the quality of care of patient suffering from CHF. In this context, home telemonitoring appears to be a promising alternative to allow healthcare professionals to follow up patient´s health status more closely and then facilitating early detection of worsening symptoms. However, the effectiveness of these interventions in real conditions has not yet been sufficiently tested, since the implementation of telemonitoring services is considerably complex. Frequently telemonitoring studies do not overcome the pilot phase and do not reach the expected success when it comes to scale and place the intervention in routine practice. The aim of the project is to define and up-scale cost-effective and sustainable telemonitoring services for patients with CHF. Definition of the organizational model and the ICT infrastructure of the telemonitoring intervention have been deeply discussed in an inter-organizational and multidisciplinary work group, reaching consensus on how to implement the services within an integrated organizational model. Both the care pathway and the technological solution have been defined in order to design a sustainable service. On one hand, the organizational model is adaptable and flexible enough to be tailored to new contexts allowing new organizations to incorporate the service into their routine practice. On the other hand, a huge effort has been done to integrate distinct technological platforms which permit that the telemonitoring data flow from patient´s home to the EHR. Short description of practice change implemented: The patient who meets the inclusion criteria and signs the informed consent is enrolled in the intervention. The technical provider is responsible for installing devices for the measurement of the heart rate, blood pressure, pulse-oxymetry and weight at patient's home within a week after recruitment. In addition, a personal alarm device for 24/7 real-time emergency detection is installed. The patient is trained in using the telemonitoring and telecare devices. Following the clinician's prescription, the patient will routinely transmit his/her parameters at least once per week. The telemonitoring devices collect and send the data wirelessly to the gateway located at his/her home. The gateway device transmits the data collected by the patient to the alarm management system of the Telecare Centre. The operator of the Telecare Centre checks the data sent by the patient and activates the predefined protocol agreed by a group of professionals, including clinicians, general practitioners, nurses, general directors and representatives of the social area. When clinical parameters are out of range, the operator first verifies the alarm situation by a phone call to the patient. If the alarm is validated, the operator triggers the protocol depending on the severity of the situation. The operator contacts the eHealth Centre composed of nurses; they then solve the alarm on their own, notify the general practitioner or the specialist, or activate Emergency Department. If the patient uses the 24/7 real-time alarm device provided, the Telecare Centre's operator can contact the Emergency Department and/or social services. In addition, the Telecare Centre also solves any technical problems arising in the use of devices. Key findings: 150 patients have been recruited from May 2014 to June 2015 and each patient has been followed up to 12 months. Preliminary results: 42.25% alarms are technical The remaining 57.75%: - 79.7% do not activate alarm - 20.3% out of range (54.8% false positive, 30.3% true alarms, 14.7% not confirmed) Healthcare activities upon alarms: - 84,1%: solved by eHealth Centre - 5,1%: solved by primary care - 10,7%: solved in secondary care High patient and caregiver satisfaction Highlights : - The organizational model using telemonitoring services model has to be well adapted to the routine practice. - Complete telemonitoring service required (device installation, maintenance and user training) - Need of both administrative management and guarantee of good quality of telemonitored data (avoiding false alarms). - Primary Care is responsible for proactive control of the patients - Distributed leadership is crucial from the implementation process perspective (clinical, managerial and methodological) - Need to share midterm results and collect feedback from front-line professionals to detect improvement areas Conclusions : We have seen that project objectives have to be completely aligned with the central organization´s strategic plan to ensure the sustainability of the services. Using corporative technological platforms and existing resource re-organization also contribute to the maintenance of the service in long term.

Introduction : An integrated care approach supported by information and communication technologies (ICT) is being deployed in the Basque Country within the European CareWell project, to best respond to the complex needs of multi-morbid patients. Our statistical analysis carried out in Donostialdea County has demonstrated that the profile of resource consumption has not shown the expected changes. The fact that no significant differences were found indicates that the aim of maintaining stability in multi-morbid patients has not been achieved. However, this is just a static view of the situation two years after the initial deployment. Although necessary, this information is not enough to assess the efficacy of the intervention since the way in which health care is organized is considered as a unitary actor, either adapting to the environment or remaining inert. Integration of health care requires the alteration of delivery processes that change over time in predictable and unpredictable ways. Some processes may be altered more quickly than others, depending on how long it takes for the health-care staff to achieve the necessary behavioural changes. The objective of this work was to apply predictive modeling adapted to the local context to develop a tool within the Deming’s plan-do-check-act (PDCA) cycle to manage continuous improvement in integrated interventions over the long term in the CareWell project. Methods : Simulation modeling techniques – Discrete Event Simulation (DES) – were used to forecast the budget impact of a new integrated intervention – which included use of electronic prescriptions and new provider roles, including reference internist, hospital liasion nurse, and advanced skills nurse – from 2012 to 2020. Predictive modeling helped us delimit the impact of the integrated health-care intervention according to the organizationally defined goals by comparing both scenarios. Resource consumption data used to populate the model –traditional health care – was obtained from administrative databases. A Delphi study was performed to determine the extent to which integrated health-care systems could avoid patient decompensation, which was measured as Accident and Emergency (A&E) service uses and hospitalizations avoided. This economic analysis assumed a reduction in emergencies by 10% during 5 years. With the simulation model, the resource-consumption rates were provided as a result. Multiplying this by the unit costs, we determined the cost of illness of multi-morbid patients with traditional health care and with a hypothetical integrated health-care organization that would achieve a reduction in emergencies by 2% annually. Combining the cost of illness allowed us to estimate the Budget Impact Analysis (BIA). Results : Predictive modeling showed that, by considering ageing of the general population, the multi-morbid patient population in Donostialdea will increase by 8% by 2020. As the target population is both larger and older, conventional health-care costs will have increased by 21%. If interventions could successfully reduce emergency costs annually by 2%, this budget would decrease 18%, with cumulative savings of over 500,000 euros in the study period. Discussion : Deming’s PDCA cycle, together with statistical analysis, is a well-known tool for management, but to our knowledge, our work is the first to demonstrate the capacity of predictive modeling as a complementary tool in managing integrated health-care models. Using DES to represent the care process and natural history of multi-morbid patients, we can forecast the economic burden associated with this population. This was possible by use of data and tools with very different origins. We combined clinical evolution, resource consumption, demographic trends, epidemiological data obtained with the Dismod II software, parametric survival analysis, economic evaluation, and simulation to inform the planning stage with a tool from the world of engineering. Integrating simulation modeling and statistical analysis within the Deming’s PDCA cycle has helped the continuous improvement of the challenging task of changing the organizational model to achieve deployment of complex interventions within integrated health-care organizations. The four stages described in the PDCA cycle mirror the scientific experimental method of formulating a hypothesis, collecting data to test the hypothesis, analysing and interpreting the results, and making inferences to iterate the hypothesis. We used modeling to formulate the hypothesis (planning) by defining two key elements derived from extrapolation of resource consumption to 2020: foreseeing the situation and setting objectives. First, modeling anticipated the increase of care cost for multi-morbid patients due to ageing in Donostialdea County. Second, it showed the cost savings if the program achieved the objective of reducing unstable conditions in patients by an annual 2%. We aimed to replicate the integrated health care by a functioning or interactive representation of the system, as opposed to purely conceptual models such as mathematical functions. This model was developed as a prototype for a certain county in the Basque. Currently we are carrying out the analysis for the whole Basque Country considering the twelve Integrated Health Care Organizations which deployed different integrated solutions. This will let us do benchmarking and apply the best solutions.

We assessed the criterion related validity of 1/2 mile run/walk (1/2MRW) test for estimating VO2peak in children aged 6-17 years. The criterion related validity of the Fernhall's equation in a sub-group of children aged 10-17 years was also examined. A total of 86 children completed a maximal graded treadmill test and the 1/2MRW test. The cohort was randomly divided into either validation (n=47) or a cross-validation (n=39) group. A regression equation was computed and assessed through several error measures, and the Bland and Altman method. There was no systematic bias in the validation group nor in the cross-validation group (P > 0.1). The root mean sum of squared errors (RMSE), and the percentage error were 6.5 ml/kg/min, and 13.9%, respectively. These figures were very similar in the cross-validation group. The new equation had a lower RMSE and percentage error than the Fernhall's Equation (6.2 vs. 19.7 ml/kg/min, and 16% vs. 50.4%, respectively, P