Exploring the variation in implementation of a COPD disease management programme and its impact on health outcomes: a post hoc analysis of the RECODE cluster randomised trial

Abstract

This study aims to (1) examine the variation in implementation of a 2-year chronic obstructive pulmonary disease (COPD) management programme called RECODE, (2) analyse the facilitators and barriers to implementation and (3) investigate the influence of this variation on health outcomes. Implementation variation among the 20 primary-care teams was measured directly using a self-developed scale and indirectly through the level of care integration as measured with the Patient Assessment of Chronic Illness Care (PACIC) and the Assessment of Chronic Illness Care (ACIC). Interviews were held to obtain detailed information regarding the facilitators and barriers to implementation. Multilevel models were used to investigate the association between variation in implementation and change in outcomes. The teams implemented, on average, eight of the 19 interventions, and the specific package of interventions varied widely. Important barriers and facilitators of implementation were (in)sufficient motivation of healthcare provider and patient, the high starting level of COPD care, the small size of the COPD population per team, the mild COPD population, practicalities of the information and communication technology (ICT) system, and hurdles in reimbursement. Level of implementation as measured with our own scale and the ACIC was not associated with health outcomes. A higher level of implementation measured with the PACIC was positively associated with improved self-management capabilities, but this association was not found for other outcomes. There was a wide variety in the implementation of RECODE, associated with barriers at individual, social, organisational and societal level. There was little association between extent of implementation and health outcomes.

The Effect of Integration of Self-Management Web Platforms on Health Status in Chronic Obstructive Pulmonary Disease Management in Primary Care (e-Vita Study): Interrupted Time Series Design

“…In our study, the median baseline CCQ score of 1.2 was low compared with scores in other primary care COPD studies, which reflects mildly symptomatic COPD [ 7 ]. This limits the room for stabilization or improvement in our primary outcome (ie, ceiling effect).…”

“…In earlier studies, a worsening in health status was found for primary care patients over a longer period of time [ 8 ]; this finding was not confirmed in our e-Vita study. In Dutch primary care, the standards of IDM are high, with a wide variety in the implementation of interventions [ 7 ]; this might explain the absence of a worsening of health status before the intervention in our study. The introduction and integration of eHealth within IDM will not make a significant difference in the short term due to the high standard of IDM.…”

“…Monitoring should contribute to delaying disease progression and alleviate its manifestations; the most important primary care objective should be to improve quality of life (QoL) [ 6 ]. In primary care COPD studies, the mean score on the Clinical COPD Questionnaire (CCQ) reflects a mildly symptomatic COPD [ 7 ], and the health status of patients was found to decline over a longer period of time [ 8 ].…”

A novel integrated care concept (NICC) versus standard care in the treatment of chronic cardiovascular diseases: protocol for the randomized controlled trial CardioCare MV

“…The novel integrated care concept (NICC) that will be investigated in this trial consists of a bundle of interventions and a specific path for patients of each disease. Boland et al [ 27 ] showed for chronic obstructive pulmonary disease that a pragmatic and non-experimental implementation of a set of interventions resulted in a low level and a wide variety of implementations across different teams. Important barriers to implementation were insufficient motivation of patients, high starting level of care, few patients per disease management team, mild disease levels in the studied population, practicalities of the disease management program and hurdles to reimbursement.…”

Diabetes care: Comparison of patients' and healthcare professionals' assessment using the PACIC instrument

“…Despite the fact that the 5‐dimensions structure of the PACIC remains debated, the PACIC questionnaire has been validated in several studies as a tool able to assess how provided care is congruent with the CCM, and judged to be appropriate both when considering a 1‐dimension score or 20 single items means . Currently, it is increasingly being used to evaluate the care of patients with chronic conditions …”