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Original article

Vol. 147 No. 4344 (2017)

Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care: a cross-sectional study

  • Corinne Chmiel
  • Irina Giewer
  • Anja Frei
  • Thomas Rosemann
Cite this as:
Swiss Med Wkly. 2017;147:w14522



Implementing the Chronic Care Model (CCM) via involvement of specially trained practice nurses improves cardiovascular risk profiles and perception of care among type 2 diabetes patients in small primary care practices (PCPs) in the short term. Little is known about the long-term effects of this intervention.


Cross-sectional survey among the participants of the cluster randomised controlled CARAT trial (30 PCPs, 303 diabetes patients), 3 years after its completion.


Proportion of patients still treated according to the CCM, possible reasons for discontinuation, glycosylated haemoglobin (HbA1c), blood pressure, low density lipoprotein cholesterol, and accordance with CCM (assessed by means of PACIC [Patient Assessment of Chronic Illness Care]).


Overall, 40.9% of practices (40.7% of patients) continued using the CCM. PCPs originally randomised to the intervention group were significantly more likely to be still using the CCM (11 PCPs / 88 patients vs 11 PCPs / 94 patients, p <0.001). Main reasons for discontinuation were organisational (40.9%) and financial aspects (18.1%), and the general practitioner refusing to transfer treatment responsibility (18.1%). HbA1c and PACIC development over the long term showed significant positive effects in favour of PCPs originally randomised to the intervention group and practices continuing to treat patients according to the CCM.


Diabetes care according to the CCM, including the involvement of trained practice nurses, is a reasonable tool to improve care in the long-term. CCM training of the whole team is essential to overcome organisational challenges. Continuous team education, technical decision support, and recognition of the importance of these new structures in healthcare policy might improve the long-term clinical effect of the team approach.

Clinical trial registration number



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