The effectiveness of a semi-tailored facilitator-based intervention to optimise chronic care management in general practice: a stepped-wedge randomised controlled trial

Tina Drud Due, Thorkil Thorsen, Marius Brostrøm Kousgaard, Volkert Dirk Siersma, Frans Boch Waldorff, Tina Drud Due, Thorkil Thorsen, Marius Brostrøm Kousgaard, Volkert Dirk Siersma, Frans Boch Waldorff

Abstract

Background: The Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice; and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention.

Method: The study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD); changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification; sign-up for a software program for patient overview; and reduction in number of practices with few annual chronic disease check-ups.

Results: We randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program.

Conclusion: The mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care.

Trial registration: ClinicalTrials.gov: NCT01297075.

Figures

Figure 1
Figure 1
Timetable.
Figure 2
Figure 2
Trial flow.
Figure 3
Figure 3
Sign up for Sentinel Data Capture. *Indicate a significant difference between the groups.

References

    1. Kronisk sygdom. Patient, sundhedsvæsen og samfund [Chronic disease. Patient, Health Service and Society] Copenhagen: The Danish Health and Medicines Authority; 2005.
    1. Improving Chronic Illness Care. 2013. .
    1. Forløbsprogrammer for kronisk sygdom - Generisk model og forløbsprogram for diabetes. [Disease management programmes - generic model and Disease management programmes for Type 2 Diabetes] Copenhagen: The Danish Health and Medicines Authority; 2008.
    1. Forløbsprogram for Type 2 Diabetes - Hospitaler, almen praksis og kommunerne i Region Hovedstaden. [Disease management programme For Type 2 Diabetes - Hospitals, general practice and municipalities in the Capital Region of Denmark] Hilleroed, Capital Region of Denmark; 2009.
    1. Forløbsprogram for KOL - Hospitaler, almen praksis og kommunerne i Region Hovedstaden. [Disease management programme for COPD - Hospitals, general practice and municipalities in the Capital Region of Denmark] Hilleroed, Capital Region of Denmark; 2009.
    1. Fullard E, Fowler G, Gray M. Facilitating prevention in primary care. Br Med J (Clin Res Ed) 1984;289:1585–1587. doi: 10.1136/bmj.289.6458.1585.
    1. Petrova M, Dale J, Munday D, Koistinen J, Agarwal S, Lall R. The role and impact of facilitators in primary care: findings from the implementation of the Gold Standards Framework for palliative care. Fam Pract. 2010;27:38–47. doi: 10.1093/fampra/cmp066.
    1. Kronikerkompasset evalueringsrapport. [The chronic care compass an evaluation report] Aarhus: The Research Unit for General Practice in Aarhus; 2012.
    1. Atkins EM, Duffy MC, Bain DJ. The practice characterization model: the importance of organizational life cycles and targeted interventions in general medical practice. Int J Health Plann Manage. 2001;16:125–138. doi: 10.1002/hpm.619.
    1. Baskerville NB, Hogg W, Lemelin J. Process evaluation of a tailored multifaceted approach to changing family physician practice patterns improving preventive care. J Fam Pract. 2001;50:W242–W249.
    1. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10:63–74. doi: 10.1370/afm.1312.
    1. Bunniss S, Gray F, Kelly D. Collective learning, change and improvement in health care: trialling a facilitated learning initiative with general practice teams. J Eval Clin Pract. 2011;18:630–636.
    1. Burtonwood AM, Hocking PJ, Elwyn G. Joining them up: the challenges of organisational change in the professional politic of general practice. J Interprof Care. 2001;15:383–393. doi: 10.1080/13561820120080508.
    1. Crotty M, Whitehead C, Rowett D, Halbert J, Weller D, Finucane P, Esterman A. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475] BMC Health Serv Res. 2004;4:6. doi: 10.1186/1472-6963-4-6.
    1. Dalsgaard T, Kallerup H, Rosendal M. Outreach visits to improve dementia care in general practice: a qualitative study. Int J Qual Health Care. 2007;19:267–273. doi: 10.1093/intqhc/mzm033.
    1. Frich JC, Hoye S, Lindbaek M, Straand J. General practitioners and tutors' experiences with peer group academic detailing: a qualitative study. BMC Fam Pract. 2010;11:12. doi: 10.1186/1471-2296-11-12.
    1. Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B, Seers K. Getting evidence into practice: the role and function of facilitation. J Adv Nurs. 2002;37:577–588. doi: 10.1046/j.1365-2648.2002.02126.x.
    1. Hogg W, Baskerville N, Nykiforuk C, Mallen D. Improved preventive care in family practices with outreach facilitation: understanding success and failure. J Health Serv Res Policy. 2002;7:195–201. doi: 10.1258/135581902320432714.
    1. Hogg W, Lemelin J, Moroz I, Soto E, Russell G. Improving prevention in primary care: Evaluating the sustainability of outreach facilitation. Can Fam Physician. 2008;54:712–720.
    1. Hogg W, Lemelin J, Graham ID, Grimshaw J, Martin C, Moore L, Soto E, O'Rourke K. Improving prevention in primary care: evaluating the effectiveness of outreach facilitation. Fam Pract. 2008;25:40–48.
    1. Janssens I, De MM, Habraken H, Soenen K, van DM, Christiaens T, Bogaert M. Barriers to academic detailers: a qualitative study in general practice. Eur J Gen Pract. 2005;11:59–63. doi: 10.3109/13814780509178239.
    1. McCowan C, Neville RG, Crombie IK, Clark RA, Warner FC. The facilitator effect: results from a four-year follow-up of children with asthma. Br J Gen Pract. 1997;47:156–160.
    1. Nagykaldi Z, Mold JW, Aspy CB. Practice facilitators: a review of the literature. Fam Med. 2005;37:581–588.
    1. Nazareth I, Freemantle N, Duggan C, Mason J, Haines A. Evaluation of a complex intervention for changing professional behaviour: the Evidence Based Out Reach (EBOR) Trial. J Health Serv Res Policy. 2002;7:230–238. doi: 10.1258/135581902320432769.
    1. O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2000. .: CD000409. doi:10.1002/14651858.CD000409.pub2.
    1. Qureshi N, Allen J, Hapgood R. A systematic review of educational outreach visits for non-prescribing interventions in general practice. Eur J Gen Pract. 2002;8:31–36. doi: 10.3109/13814780209160826.
    1. Rhydderch M, Edwards A, Marshall M, Elwyn G, Grol R. Developing a facilitation model to promote organisational development in primary care practices. BMC Fam Pract. 2006;7:38. doi: 10.1186/1471-2296-7-38.
    1. Stevens SA, Cockburn J, Hirst S, Jolley D. An evaluation of educational outreach to general practitioners as part of a statewide cervical screening program. Am J Public Health. 1997;87:1177–1181. doi: 10.2105/AJPH.87.7.1177.
    1. Watkins C, Timm A, Gooberman-Hill R, Harvey I, Haines A, Donovan J. Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study. Fam Pract. 2004;21:661–669. doi: 10.1093/fampra/cmh614.
    1. Zwarenstein M, Bheekie A, Lombard C, Swingler G, Ehrlich R, Eccles M, Sladden M, Pather S, Grimshaw J, Oxman AD. Educational outreach to general practitioners reduces children's asthma symptoms: a cluster randomised controlled trial. Implement Sci. 2007;2:30. doi: 10.1186/1748-5908-2-30.
    1. Praksisbesøg i Region Syddanmark. [practice visits in Region Southern Denmark] 2013. .
    1. Dalsgaard T, Rosendal M. [Motivation and barriers to the use of facilitator visits in general practice] Ugeskr Laeger. 2008;170:731–735.
    1. Eriksson T, Siersma VD, Logstrup L, Buch MS, Elwyn G, Edwards A. Documenting organisational development in general practice using a group-based assessment method: the Maturity Matrix. Qual Saf Health Care. 2010;19:e37. doi: 10.1136/qshc.2007.026187.
    1. Kousgaard MB, Thorsen T. Positive experiences with a specialist as facilitator in general practice. Dan Med J. 2012;59:A4443.
    1. Smidth M, Christensen MB, Olesen F, Vedsted P. Developing an active implementation model for a chronic disease management program. Int J Integr Care. 2013;13:e020.
    1. Lemelin J, Hogg W, Baskerville N. Evidence to action: a tailored multifaceted approach to changing family physician practice patterns and improving preventive care. CMAJ. 2001;164:757–763.
    1. Dickinson WP, Dickinson LM, Nutting PA, Emsermann CB, Tutt B, Crabtree BF, Fisher L, Harbrecht M, Gottsman A, West DR. Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial. Ann Fam Med. 2014;12:8–16. doi: 10.1370/afm.1591.
    1. Parchman ML, Noel PH, Culler SD, Lanham HJ, Leykum LK, Romero RL, Palmer RF. A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects. Implement Sci. 2013;8:93. doi: 10.1186/1748-5908-8-93.
    1. Brown CA, Lilford RJ. The stepped wedge trial design: a systematic review. BMC Med Res Methodol. 2006;6:54. doi: 10.1186/1471-2288-6-54.
    1. Mdege ND, Man MS, Taylor nee Brown CA, Torgerson DJ. Systematic review of stepped wedge cluster randomized trials shows that design is particularly used to evaluate interventions during routine implementation. J Clin Epidemiol. 2011;64:936–948. doi: 10.1016/j.jclinepi.2010.12.003.
    1. Schroll H, Christensen RD, Thomsen JL, Andersen M, Friborg S, Sondergaard J. The danish model for improvement of diabetes care in general practice: impact of automated collection and feedback of patient data. Int J Family Med. 2012;2012:208123.
    1. Andersen JS, Olivarius NF, Krasnik A. The Danish National Health Service Register. Scand J Public Health. 2011;39:34–37. doi: 10.1177/1403494810394718.
    1. Frijling BD, Lobo CM, Hulscher ME, Akkermans RP, Braspenning JC, Prins A, van der Wouden JC, Grol RP. Multifaceted support to improve clinical decision making in diabetes care: a randomized controlled trial in general practice. Diabet Med. 2002;19:836–842. doi: 10.1046/j.1464-5491.2002.00810.x.
    1. Kinsinger LS, Harris R, Qaqish B, Strecher V, Kaluzny A. Using an office system intervention to increase breast cancer screening. J Gen Intern Med. 1998;13:507–514. doi: 10.1046/j.1525-1497.1998.00160.x.
    1. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334–344. doi: 10.3122/jabfm.2008.04.080006.
    1. Dietrich AJ FAU, O'Connor GT FAU, Keller AF, Carney PA FAU, Levy DF, Whaley FS. Cancer: improving early detection and prevention. A community practice randomised trial. BMJ. 1992;304:687–691. doi: 10.1136/bmj.304.6828.687.
    1. Modell M, Wonke B, Anionwu E, Khan M, Tai SS, Lloyd M, Modell B. A multidisciplinary approach for improving services in primary care: randomised controlled trial of screening for haemoglobin disorders. BMJ. 1998;317:788–791. doi: 10.1136/bmj.317.7161.788.

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