Implementation of chronic illness care in German primary care practices – how do multimorbid older patients view routine care? A cross-sectional study using multilevel hierarchical modeling

BMC Health Services Research

Anne Dahlhaus²  Martin Scherer⁹  Hendrik van den Bussche⁹  Birgitt Wiese⁶  Hans-Helmut König⁵  Horst Bickel¹  Wolfgang Maier³  Angela Fuchs⁷  Steffi G Riedel-Heller^1,10  Siegfried Weyerer⁴  Heike Hansen⁹  Jochen Gensichen⁸  Karola Mergenthal²  Michael A Paulitsch²  Juliana J Petersen² 

[1] Department of Psychiatry, Technical University of Munich, Ismaninger Str. 22, München 81675, Germany;Institute of General Practice, Goethe-University Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt/Main 60590, Germany;Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, Bonn 53105, Germany;Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, J5, Mannheim 68159, Germany;Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany;Working Group Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Hannover 30625, Germany;Institute of General Practice, University of Düsseldorf, Moorenstraße 5, Düsseldorf 40225, Germany;Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University, Bachstraße 18, Jena 07743, Germany;Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany;Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Straße 55, Leipzig 04103, Germany

关键词: Patient-centred care;    Assessment of care;    Chronic care model;    Multimorbidity;    Chronic disease;   

Others  :  1126823
DOI  :  10.1186/1472-6963-14-336

 received in 2014-02-07, accepted in 2014-07-29,  发布年份 2014

【 摘 要 】

Background

In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views.

Methods

This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice).

Results

The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice.

Conclusions

This study shows that from the perspective of multimorbid patients receiving care in German primary care practices, the implementation of structured care and counseling could be improved, particularly by helping patients set specific goals, coordinating care, and arranging follow-up contacts. Studies evaluating chronic care should take into consideration that a patient’s assessment is associated not only with practice-level factors, but also with individual, patient-level factors.

Trial registration

Current Controlled Trials ISRCTN89818205.

【 授权许可】

   
2014 Petersen et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L: Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005, 3:223-228.
• [2]Glynn LG, Valderas JM, Healy P, Burke E, Newell J, Gillespie P, Murphy AW: The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract 2011, 28:516-523.
• [3]Muth C, Beyer M, Fortin M, Rochon J, Oswald F, Valderas JM, Harder S, Glynn LG, Perera R, Freitag M, Kaspar R, Gensichen J, van den Akker M: Multimorbidity’s research challenges and priorities from a clinical perspective: The case of ‘Mr Curran’. Eur J Gen Pract 2014, 20:139-147.
• [4]Fortin M, Bravo G, Hudon C, Lapointe L, Almirall J, Dubois MF, Vanasse A: Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res 2006, 15:83-91.
• [5]Glynn LG, Buckley B, Reddan D, Newell J, Hinde J, Dinneen SF, Murphy AW: Multimorbidity and risk among patients with established cardiovascular disease: a cohort study. Br J Gen Pract 2008, 58:488-494.
• [6]Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, Blumenthal D: Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med 2007, 22(Suppl. 3):391-395.
• [7]RAND CORPORATION: DISMEVAL Developing and validating disease management evaluation methods for European healthcare systems - final report. In Edited by Ellen Nolte and Saba Hinrichs on behalf of the DISMEVAL Consortium. 2012. Access at: http://ww.rand.org/pubs/technical_reports/TR1226.html webcite. Last access: 21.5.2014
• [8]Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A: Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001, 20:64-78.
• [9]Gensichen J, Muth C, Butzlaff M, Rosemann T, Raspe H, de Cornejo GM, Beyer M, Härter M, Müller UA, Angermann CE, Gerlach FM, Wagner E: Die Zukunft ist chronisch: das Chronic Care-Modell in der deutschen Primärversorgung. Übergreifende Behandlungsprinzipien einer proaktiven Versorgung für chronische Kranke [The future is chronic: German primary care and the Chronic Care Model - the comprehensive principles in the proactive treatment of the chronically ill]. Z Arztl Fortbild Qualitatssich 2006, 100:365-374.
• [10]Group Health Research Institute: The Chronic Care Model. Access at: http://www.improvingchroniccare.org/index.php?p=Delivery_System_Design&s=21 webcite. Last access: 21.5.2014
• [11]Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002, 288:1909-1914.
• [12]Tsai AC, Morton SC, Mangione CM, Keeler EB: A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care 2005, 11:478-488.
• [13]Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, Glasgow RE: Use of chronic care model elements is associated with higher-quality care for diabetes. Ann Fam Med 2007, 5:14-20.
• [14]Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM: Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Med Care 2005, 43:436-444.
• [15]Spicer J, Budge C, Carryer J: Taking the PACIC back to basics: the structure of the Patient Assessment of Chronic Illness Care. J Eval Clin Pract 2012, 18:307-312.
• [16]van Lieshout J, Steenkamer B, Knippenberg M, Wensing M: Improvement of primary care for patients with chronic heart failure: A study protocol for a cluster randomised trial comparing two strategies. Implement Sci 2011, 6:28.
• [17]Rosemann T, Laux G, Droesemeyer S, Gensichen J, Szecsenyi J: Evaluation of a culturally adapted German version of the Patient Assessment of Chronic Illness Care (PACIC 5A) questionnaire in a sample of osteoarthritis patients. J Eval Clin Pract 2007, 13:806-813.
• [18]Wensing M, Van LJ, Jung HP, Hermsen J, Rosemann T: The Patients Assessment Chronic Illness Care (PACIC) questionnaire in The Netherlands: a validation study in rural general practice. BMC Health Serv Res 2008, 8:182-188.
• [19]Szecsenyi J, Rosemann T, Joos S, Peters-Klimm F, Miksch A: German diabetes disease management programs are appropriate for restructuring care according to the chronic care model: an evaluation with the patient assessment of chronic illness care instrument. Diabetes Care 2008, 31:1150-1154.
• [20]Cramm J, Nieboer A: The chronic care model: congruency and predictors among patients with cardiovascular diseases and chronic obstructive pulmonary disease in the Netherlands. BMC Health Serv Res 2012, 12:242.
• [21]Ludt S, van Lieshout J, Campbell SM, Rochon J, Ose D, Freund T, Wensing M, Szecsenyi J: Identifying factors associated with experiences of coronary heart disease patients receiving structured chronic care and counselling in European primary care. BMC Health Serv Res 2012, 12:221-12.
• [22]Schäfer I, Hansen H, Schön G, Maier W, Höfels S, Altiner A, Fuchs A, Gerlach FM, Petersen JJ, Gensichen J, Schulz S, Riedel-Heller S, Luppa M, Weyerer S, Werle J, Bickel H, Barth K, König HH, Rudolph A, Wiese B, Prokein J, Bullinger M, von dem Knesebeck O, Eisele M, Kaduszkiewicz H, Wegscheider K, van den Bussche H: The German MultiCare-study: Patterns of multimorbidity in primary health care - protocol of a prospective cohort study. BMC Health Serv Res 2009, 9:145-149.
• [23]Brauns H, Steinmann S: Educational reform in France, West-Germany and the United Kingdom: Updating the CASMIN educational classification. ZUMA-Nachrichten 1999, 44:7-44.
• [24]Ahrens W, Bellach BM, Jöckel KH: Messung soziodemographischer Merkmale in der Epidemiologie [Measurement of sociodemographic factors in epidemiology]. München: Urban & Vogel; 1998.
• [25]van den Bussche H, Koller D, Kolonko T, Hansen H, Wegscheider K, Glaeske G, von Leitner EC, Schäfer I, Schön G: Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 2011, 11:101-111.
• [26]Schäfer I, Hansen H, Schön G, Höfels S, Altiner A, Dahlhaus A, Gensichen J, Riedel-Heller S, Weyerer S, Blank WA, König HH, von dem Knesebeck O, Wegscheider K, Scherer M, van den Bussche H, Wiese B: The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. First results from the MultiCare cohort study. BMC Health Serv Res 2012, 12:89.
• [27]Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, Meinow B, Fratiglioni L: Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev 2011, 10:430-439.
• [28]Lawton MP, Brody EM: Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 1969, 9:179-186.
• [29]EuroQol group: EuroQol - a new facility for the measurement of health-related quality of life. Health Policy 1990, 16:199-208.
• [30]Von Korff M, Ormel J, Keefe FJ, Dworkin SF: Grading the severity of chronic pain. Pain 1992, 50:133-149.
• [31]Sheikh J, Yesavage J: Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist 1986, 5:165-173.
• [32]Hinz A, Schumacher J, Albani C, Schmid G, Brähler E: Bevölkerungsrepräsentative Normierung der Skala zur Allgemeinen Selbstwirksamkeitserwartung [Standardization of the General Self-Efficacy Scale in the German population]. Diagnostica 2006, 52:26-32.
• [33]Fydrich T, Sommer G, Brähler E: F-SozU Fragebogen zur Sozialen Unterstützung. [F-SozU: Questionnaire on social support]. Göttingen: Hogrefe; 2007.
• [34]Sherbourne CD: The role of social support and life stress events in use of mental health services. Soc Sci Med 1988, 27:1393-1400.
• [35]Hall JA, Dornan MC: Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med 1990, 30:811-818.
• [36]Andridge RR, Little RJ: A review of hot deck imputation for survey non-response. Int Stat Rev 2010, 78:40-64.
• [37]D’Orazio M: StatMatch: Statistical Matching. 2009. Access at: http://cran.r-project.org/ webcite. Last access: 1.5.2014
• [38]Raudenbush A, Bryk S, Cheong YF, Congdon R, Du Toit M: Hierarchical linear and nonlinear modeling (HLM7). Lincolnwood, USA: Scientific Software International; 2011.
• [39]IBM Corp: IBM SPSS Statistics for Windows, version 19. Armonk, NY: Released 2010; 2013.
• [40]Ludt S, Heiss F, Glassen K, Noest S, Klingenberg A, Ose D, Szecsenyi J: Die Patientenperspektive jenseits ambulant-stationärer Sektorengrenzen - Was ist Patientinnen und Patienten in der sektorenübergreifenden Versorgung wichtig? [Patients’ perspectives beyond sectoral borders between inpatient and outpatient care - patients’ experiences and preferences along cross-sectoral episodes of care.]. Gesundheitswesen 2014, 76:359-65.
• [41]Cramm JM, Nieboer AP: Factorial validation of the Patient Assessment of Chronic Illness Care (PACIC) and PACIC short version (PACIC-S) among cardiovascular disease patients in the Netherlands. Health Qual Life Outcomes 2012, 10:104.
• [42]Gensichen J, Serras A, Paulitsch MA, Rosemann T, König J, Gerlach FM, Petersen JJ: The Patient Assessment of Chronic Illness Care questionnaire: evaluation in patients with mental disorders in primary care. Community Ment Health J 2011, 47:447-453.
• [43]Cramm JM, Nieboer AP: High-quality chronic care delivery improves experiences of chronically ill patients receiving care. Int J Qual Health Care 2013, 25:689-695.
• [44]Levesque JF, Feldman DE, Lemieux V, Tourigny A, Lavoie JP, Tousignant P: Variations in patients’ assessment of chronic illness care across organizational models of primary health care: a multilevel cohort analysis. Healthc Policy 2012, 8:e108-e123.
• [45]Salisbury C, Wallace M, Montgomery AA: Patients’ experience and satisfaction in primary care: secondary analysis using multilevel modelling. BMJ 2010, 341:c5004.
• [46]Ridd M, Shaw A, Lewis G, Salisbury C: The patient-doctor relationship: a synthesis of the qualitative literature on patients’ perspectives. Br J Gen Pract 2009, 59:e116-e133.
• [47]Muller C: Health and health care of employed adults: occupation and gender. Women Health 1986, 11:27-45.
• [48]Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B: Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012, 380:37-43.
• [49]Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T: Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2012., 4CD006560
• [50]Gerlach FM, Szecsenyi J: Hausarztzentrierte Versorgung in Baden-Württemberg - Konzept und Ergebnisse der kontrollierte Begleitevaluation [Family doctor-centred care in Baden-Wuerttemberg: concept and results of a controlled evaluation study]. Z Evid Fortbild Qual Gesundhwes 2013, 107:365-371.
• [51]Mergenthal K, Beyer M, Güthlin C, Gerlach FM: Evaluation des VERAH-Einsatzes in der Hausarztzentrierten Versorgung in Baden-Württemberg [Evaluating the deployment of VERAHs in family doctor-centred health care in Baden-Wuerttemberg]. Z Evid Fortbild Qual Gesundhwes 2013, 107:386-393.
• [52]Gensichen J, Von KM, Peitz M, Muth C, Beyer M, Guthlin C, Torge M, Petersen JJ, Rosemann T, König J, Gerlach FM: Case management for depression by health care assistants in small primary care practices: a cluster randomized trial. Ann Intern Med 2009, 151:369-378.
• [53]Rosemann T, Joos S, Laux G, Gensichen J, Szecsenyi J: Case management of arthritis patients in primary care: a cluster-randomized controlled trial. Arthritis Rheum 2007, 57:1390-1397.
• [54]Freund T, Wensing M, Mahler C, Gensichen J, Erler A, Beyer M, Gerlach FM, Szecsenyi J, Peters-Klimm F: Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: A study protocol. Implement Sci 2010, 5:70.
• [55]Gugiu C, Coryn CL, Applegate B: Structure and measurement properties of the Patient Assessment of Chronic Illness Care instrument. J Eval Clin Pract 2010, 16:509-516.
• [56]Wensing M, Baker R, Szecsenyi J, Grol R: Impact of national health care systems on patient evaluations of general practice in Europe. Health Policy 2004, 68:353-357.