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Understanding how to improve chronic care
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Drewes, H. W. (2012). Understanding how to improve chronic care: Using variation to gain insight Enschede:
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Download date: 29. apr. 2016
Understanding how to improve chronic care:
using variation to gain insight Hanneke Drewes
Understanding how to improve chronic care:
using variation to gain insight Hanneke Wil-Trees Drewes The research described in this thesis was carried out at the Department of Tranzo, Tilburg University and the Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment (RIVM).
The studies described in this thesis were financed by the National Institute for Public Health and the Environment and the Dutch Health Care Inspectorate (IGZ).
Financial support for the publication of this thesis by the National Institute for Public Health and the Environment and Tilburg University is gratefully acknowledged.
Cover design: Robert Wevers Lay-out and printing: Gildeprint Drukkerijen, Enschede, the Netherlands ISBN: 978-94-6108-358-6 ©H.W. Drewes, 2012 All rights reserved. No parts of this publication may be reproduced in any form without permission of the author.
Understanding how to improve chronic care:
using variation to gain insight Proefschrift ter verkrijging van de graad van doctor aan Tilburg University op gezag van de rector magnificus, prof. dr. Ph. Eijlander, in het openbaar te verdedigen ten overstaan van een door het college voor promoties aangewezen commissie in de aula van de Universiteit op woensdag 21 november 2012 om 16.15 uur door
Part 1: Explaining the variation in effectiveness between chronic care management evaluations Chapter 2 The effectiveness of chronic care management for heart failure: 21 meta-regression analyses to explain the heterogeneity in outcomes Chapter 3 Chronic care management: how to best deal with the variation in its 49 effectiveness?
Part 2: Exploring the association between chronic care management and patient outcomes in daily care practice Chapter 4 Differences in patient outcomes and chronic care management of oral 65 anticoagulant therapy: an explorative study Chapter 5 Measuring chronic care management experiences of patients with 79 diabetes: PACIC and PACIC+ validation Chapter 6 Exploring the association between patient experiences and outcomes 97 of diabetes care Part 3: Exploring the variation in implementing chronic care management Chapter 7 Needs and barriers to improve the cooperation in oral anticoagulant 113 therapy: a qualitative study.
Context Chronic diseases pose significant challenges to health care systems worldwide1-3. Many countries have to deal with a tremendous burden of chronic diseases because the mortality and morbidity are higher than that of any other condition. The number of people with chronic diseases is even expected to increase which can partly be attributed to the double ageing of the population1, 4. Besides the fact that countries have to deal with an increased need of chronic care services, health care systems traditionally fail to meet the needs of people with chronic diseases. In particular, the passive role of the patient combined with the reactive and fragmentised physician care that characterise many health care systems are inappropriate for people with chronic care demands2, 5-7. Meanwhile, countries have to deal with pervasive quality of care problems. Chronic care is more than once not congruent to the evidence based medicine incorporated in guidelines and protocols8. In addition, unexplained variation in the delivery of health care services still exists9. Thus, many countries are questioning which actions are needed to improve chronic care.
Chronic care management During the past decades, numerous interventions such as disease management and integrated care programs were introduced to redesign chronic care1, 2. These so-called ‘chronic care management’ initiatives all have their own specific characteristics10. For instance, disease management interventions focus on a single disease, whereas integrated care interventions focus on the total medical condition of the patient. Although differences can be identified between these interventions, they are all multicomponent interventions that strive for quite similar intermediate goals, namely, to improve the cooperation between professionals, foster patient-centeredness, promote evidence-based medicine, and adopt a pro-active approach to improve quality of care. In addition, all initiatives include several chronic care model (CCM) components.
The CCM of Wagner is a widely accepted guide to improve chronic care (Figure 1)11, 12.
The CCM consists of six components that all support chronic care to achieve the best possible chronic care management. Four CCM components should be incorporated at the practice level. The first component is self-management support which aims to help patients live with their condition. For example, this includes the structural incorporation of motivational interviewing in regular consultations and patient-guidelines. The second component, delivery system design, considers the organisation of the care provision, which could become more appropriate for instance by pro-actively scheduling consultations. Third, decision support, focusses on the integration of evidence-based clinical guidelines into practice, for instance by the implementation of reminder systems. The fourth component, clinical information system, aims to capture and use critical information such as feedback on professionals’ performance. The fifth component is the health care system/ organisation, in
which the above-mentioned components are applied and should ideally be facilitated. The health care system/ organisation can support chronic care management by elements such as the introduction of a board that facilitates quality improvement and the incorporation of quality improvement cycles like the plan-do-check action cycle. The last, yet certainly not the least important component, the community, encompasses all elements in the support of chronic care that lie outside the health system, such as governmental payment reforms12,.
Because the CCM is the most widely accepted and applied model to improve chronic
Chapter 1care, we defined chronic care management as the incorporation of CCM components to the care of patients with chronic diseases. As defined by the World Health Organization (WHO), patients with chronic diseases. As defined by that World Health Organization (WHO), over a a chronic disease refers to health problems the require continuous management a chronic disease of years or decades14.
period refers to health problems that require continuous management over a period of years or decades14.
Figure 1: The Chronic Care Model (CCM) 12Figure 1: The Chronic Care Model (CCM)12
Effects of chronic care management elements based on the literature Effects of chronic care management elements based on reviews exploring the effectiveness of Particularly in the past decade, many studies and the literature Particularly in the past decade, many studies havereviews published. Mixed results of chronic care chronic care management interventions and been exploring the effectiveness have been management interventionsthe effectiveness of chronic resultsmanagement interventions for to reported with regard to have been published. Mixed care have been reported with regard 1, 11, 15 the effectiveness of chronic care management interventions chronic diseases, such as chronic as chronic diseases in general1, 11, 15 as well as for specific for chronic diseases in general well as for specific chronic diseases, such as, depression18, 19, diabetes20, 21, and heart failure22, 17, 16, obstructive pulmonary diseases (COPD)16, 17 chronic obstructive pulmonary diseases (COPD) depression18, 19, diabetes20, 21, and heart failure22, 23.
The variation of effectiveness between chronic care management interventions spans a range of various outcome and process measures. For instance, a review of chronic care management interventions showed inconclusive results on quality of life for patients with asthma, depression, diabetes, and heart failure. Most studies reported no significant improvement or slight deterioration in the quality of life, yet there were also studies that reported significant positive and negative
General introductionThe variation of effectiveness between chronic care management interventions spans a range of various outcome and process measures. For instance, a review of chronic care management interventions showed inconclusive results on quality of life for patients with asthma, depression, diabetes, and heart failure. Most studies reported no significant improvement or slight deterioration in the quality of life, yet there were also studies that reported significant positive and negative effects15. Similar variation in results on process and outcome measures was identified in disease-specific reviews. For example, mixed results were observed in a study of chronic heart failure interventions based on outcome measures such as hospitalisation and mortality23.
It is important to understand how this variation arose to enable application of the most appropriate chronic care management intervention. Previous reviews also tried to explain the variation in effectiveness of chronic care management interventions by subgroup analyses21,. Although subgroup analyses were frequently applied to identify crucial elements of 23-25 chronic care management interventions, meta-regression analysis should be used instead26.
Meta-regression analyses, however, are only rarely performed18, 27. For instance, it remains unknown to what extent the comprehensiveness of chronic care management interventions is associated with the effectiveness of chronic care (e.g., clinical outcomes). True insight in the variation in effectiveness between chronic care management interventions is still lacking.
Effects of chronic care management elements in daily care practice Even though heterogeneity in outcomes between chronic care management evaluations existed, the overall effectiveness on the quality of care is expected to be positive in most countries. Positive results were also found in the Netherlands. For COPD, the bottomup implementation of disease management programs led to statistically significant improvement in various quality of life dimensions, dyspnoea, and patient experiences28. For patients with diabetes, an association was shown between disease management programs and several outcome measures, such as health-related quality of life and compliance with self-care behaviour29.
Hence, many health care professionals, managers, and policy makers introduce or facilitate chronic care management components. The available evidence regarding chronic care management, however, is still limited. In addition to the unexplained variations in outcomes, which has limited the insight into the successful elements of chronic care, the field is also hampered by previous studies that were mostly based on intervention studies performed by highly motivated practices with pre-dominantly pre-post analysis11.
Furthermore, most studies ignored the multilevel structure in evaluations30. In addition to the influence of the patient characteristics on the patient outcomes, the patient outcomes (and, thus, effectiveness) are most likely also influenced by clustering at the second level,
such as the GP practice. However, it is unknown to what extent the effectiveness of chronic care management is associated with the second level.
Given the limitations of previous research, it is of great interest to further scrutinise the currently inconclusive results by studying the association of chronic care management with structure, process, and outcome variables in daily chronic care practice.
Implementing chronic care management Variation in chronic care managements’ effectiveness can besides intervention and evaluation characteristics also be explained by its implementation process31-33. Incorporating chronic care management requires modifying medical practices and thus behavioural changes of professionals and patients. This requirement implies that many alternative factors, in addition to those directly related to the professionals and the patients, influence the overall effectiveness11, 34, 35. One of the major counterproductive determinants for the sustainability of chronic care management interventions was the workload of health care professionals and financial constraints by fragmentised payment systems36.