Skip to main navigation menu Skip to main content Skip to site footer

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
DOI
https://doi.org/10.4414/smw.2017.14522
Cite this as:
Swiss Med Wkly. 2017;147:w14522
Published
27.10.2017

Summary

AIMS

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.

METHODS

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

OUTCOMES

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]).

RESULTS

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.

CONCLUSIONS

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

ISRCTN05947538.

References

  1. Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4–14. doi:.https://doi.org/10.1016/j.diabres.2009.10.007
  2. OECD/WHO. OECD Reviews of health systems: Switzerland 2011. OECD Publishing; 2011.
  3. Chmiel C, Birnbaum B, Gensichen J, Rosemann T, Frei A. Das Diabetes-Ampelschema - Entwicklung eines Instruments für das hausärztliche Case Management bei Patienten mit Diabetes mellitus. Praxis (Bern). 2011;100(24):1457–73. Article in German. doi:.https://doi.org/10.1024/1661-8157/a000751
  4. Frei A, Chmiel C, Schläpfer H, Birnbaum B, Held U, Steurer J, et al. The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial. Cardiovasc Diabetol. 2010;9(1):23. doi:.https://doi.org/10.1186/1475-2840-9-23
  5. Frei A, Herzog S, Woitzek K, Held U, Senn O, Rosemann T, et al. Characteristics of poorly controlled Type 2 diabetes patients in Swiss primary care. Cardiovasc Diabetol. 2012;11(1):70. doi:.https://doi.org/10.1186/1475-2840-11-70
  6. Frei A, Senn O, Chmiel C, Reissner J, Held U, Rosemann T. Implementation of the chronic care model in small medical practices improves cardiovascular risk but not glycemic control. Diabetes Care. 2014;37(4):1039–47. doi:.https://doi.org/10.2337/dc13-1429
  7. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH. Improving the quality of health care for chronic conditions. Qual Saf Health Care. 2004;13(4):299–305. doi:.https://doi.org/10.1136/qshc.2004.010744
  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(6):64–78. doi:.https://doi.org/10.1377/hlthaff.20.6.64
  9. American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care. 2010;33(Suppl 1):S11–61. doi:. Corrected in: Diabetes Care 2010:33(3):692. https://doi.org/10.2337/dc10-S011
  10. Schweizerischer Verband medizinischer Praxisassistentinnen. Available from: http://www.sva.ch/no_cache/bildung/weiterbildung/diabetes.html.
  11. 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(5):436–44. doi:.https://doi.org/10.1097/01.mlr.0000160375.47920.8c
  12. 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(5):806–13. doi:.https://doi.org/10.1111/j.1365-2753.2007.00786.x
  13. Ritchie JLJ. Qualitative research practice: a guide for social science students and researchers. London: Sage Publishing; 2003.
  14. Global Health Workforce Alliance and World Health Organization. A universal truth: No health without a workforce. Geneva: World health Organization: 2013.
  15. Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. Lancet. 2008;371(9613):668–74. doi:.https://doi.org/10.1016/S0140-6736(08)60305-0
  16. Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med. 2007;82(9):827–8. doi:.https://doi.org/10.1097/ACM.0b013e31812f7939
  17. Laurant M, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev. 2009;66(6, Suppl):36S–89S. doi:.https://doi.org/10.1177/1077558709346277
  18. Kreitzer MJ, Kligler B, Meeker WC. Health professions education and integrative healthcare. Explore (NY). 2009;5(4):212–27. doi:.https://doi.org/10.1016/j.explore.2009.05.012
  19. Norman I, Normand C, Watson R, Draper J, Jowett S, Coster S. Calculating the costs of work-based training: the case of NHS Cadet Schemes. Int J Nurs Stud. 2008;45(9):1310–8. doi:.https://doi.org/10.1016/j.ijnurstu.2007.10.004
  20. Martínez-González NA, Rosemann T, Tandjung R, Djalali S. The effect of physician-nurse substitution in primary care in chronic diseases: a systematic review. Swiss Med Wkly. 2015;145:w14031.
  21. Martínez-González NA, Rosemann T, Djalali S, Huber-Geismann F, Tandjung R. Task-Shifting From Physicians to Nurses in Primary Care and its Impact on Resource Utilization: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Med Care Res Rev. 2015;72(4):395–418. doi:.https://doi.org/10.1177/1077558715586297
  22. Martínez-González NA, Tandjung R, Djalali S, Rosemann T. The impact of physician-nurse task shifting in primary care on the course of disease: a systematic review. Hum Resour Health. 2015;13(1):55. doi:.https://doi.org/10.1186/s12960-015-0049-8
  23. Drewes HW, Steuten LM, Lemmens LC, Baan CA, Boshuizen HC, Elissen AM, et al. The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes. Health Serv Res. 2012;47(5):1926–59. doi:.https://doi.org/10.1111/j.1475-6773.2012.01396.x
  24. Elissen AM, Steuten LM, Lemmens LC, Drewes HW, Lemmens KM, Meeuwissen JA, et al. Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes. J Eval Clin Pract. 2013;19(5):753–62.
  25. Lemmens KM, Lemmens LC, Boom JH, Drewes HW, Meeuwissen JA, Steuten LM, et al. Chronic care management for patients with COPD: a critical review of available evidence. J Eval Clin Pract. 2013;19(5):734–52.
  26. Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust. 2004;180(6, Suppl):S57–60.
  27. Busetto L, Luijkx KG, Elissen AM, Vrijhoef HJ. Context, mechanisms and outcomes of integrated care for diabetes mellitus type 2: a systematic review. BMC Health Serv Res. 2016;16(1):18. doi:.https://doi.org/10.1186/s12913-015-1231-3
  28. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis. 2013;10:120180. doi:.https://doi.org/10.5888/pcd10.120180
  29. Smith SM, Paul G, Kelly A, Whitford DL, O’Shea E, O’Dowd T. Peer support for patients with type 2 diabetes: cluster randomised controlled trial. BMJ. 2011;342(feb15 1):d715. doi:.https://doi.org/10.1136/bmj.d715
  30. Rydén L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer M-J, et al.; Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC); European Association for the Study of Diabetes (EASD). Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. Eur Heart J. 2007;28(1):88–136.
  31. Boyd CM, Vollenweider D, Puhan MA. Informing evidence-based decision-making for patients with comorbidity: availability of necessary information in clinical trials for chronic diseases. PLoS One. 2012;7(8):e41601. doi:.https://doi.org/10.1371/journal.pone.0041601
  32. Rydén L, Grant PJ, Anker SD, Berne C, Cosentino F, Danchin N, et al., Document Reviewers. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). Eur Heart J. 2013;34(39):3035–87. doi:.https://doi.org/10.1093/eurheartj/eht108
  33. Martínez-González NA, Tandjung R, Djalali S, Huber-Geismann F, Markun S, Rosemann T. Effects of physician-nurse substitution on clinical parameters: a systematic review and meta-analysis. PLoS One. 2014;9(2):e89181. doi:.https://doi.org/10.1371/journal.pone.0089181
  34. Martínez-González NA, Djalali S, Tandjung R, Huber-Geismann F, Markun S, Wensing M, et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14(1):214. doi:.https://doi.org/10.1186/1472-6963-14-214
  35. Adams SG, Smith PK, Allan PF, Anzueto A, Pugh JA, Cornell JE. Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management. Arch Intern Med. 2007;167(6):551–61. doi:.https://doi.org/10.1001/archinte.167.6.551
  36. Parchman ML, Pugh JA, Wang CP, Romero RL. Glucose control, self-care behaviors, and the presence of the chronic care model in primary care clinics. Diabetes Care. 2007;30(11):2849–54. doi:.https://doi.org/10.2337/dc06-2516
  37. Parchman ML, Zeber JE, Romero RR, Pugh JA. Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: a STARNet study. Med Care. 2007;45(12):1129–34. doi:.https://doi.org/10.1097/MLR.0b013e318148431e
  38. Sunaert P, Bastiaens H, Nobels F, Feyen L, Verbeke G, Vermeire E, et al. Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium. BMC Health Serv Res. 2010;10(1):207. doi:.https://doi.org/10.1186/1472-6963-10-207
  39. Piatt GA, Orchard TJ, Emerson S, Simmons D, Songer TJ, Brooks MM, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811–7. doi:.https://doi.org/10.2337/diacare.29.04.06.dc05-1785
  40. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, et al. Use of chronic care model elements is associated with higher-quality care for diabetes. Ann Fam Med. 2007;5(1):14–20. doi:.https://doi.org/10.1370/afm.610

Most read articles by the same author(s)

<< < 1 2 3 > >>