Integration of chronic disease prevention and management services into primary care: a pragmatic randomized controlled trial (PR1MaC)

Abstract

C hronic conditions are the most common problems in health care and the leading causes of death globally. 1 Acute communicable diseases have given way to chronic conditions such as arthritis, diabetes, and cardiovascular and respiratory diseases that will impose an even greater burden in the future. 2 The needs of patients with these diseases are usually complex and are challenging to manage. For this reason, many chronic disease prevention and management (CDPM) programs have been designed with the aim of improving outcomes in these patients. CDPM programs targeting diabetes, 3-7 asthma, 8,9 heart diseases, [10][11][12] costs, adherence to medication, disease control, use of health services, quality of life and mortality. However, these studies were conducted in different settings and were based on single diseases.Interventions oriented toward single diseases take little account of the multiple morbidities experienced by most patients in primary care. To date, the appropriateness of using Background: Chronic disease prevention and management programs are usually single-disease oriented. Our objective was to evaluate an intervention that targeted multiple chronic conditions and risk factors. Methods:We conducted a pragmatic randomized controlled trial involving patients aged 18-75 years with at least 1 of the targeted chronic conditions or risk factors from 8 primary care practices in the Saguenay region of Quebec, Canada, to evaluate an intervention that included self-management support and patient-centred motivational approaches. Self-management (primary outcome) was evaluated using the Health Education Impact Questionnaire (heiQ). Secondary outcomes included self-efficacy, health-related quality of life, psychological distress and health behaviours.Results: Three hundred thirty-two patients were recruited and randomly assigned (n = 166 for both intervention and control groups) and evaluated after 3 months. The intervention group showed improvement in 6 of the 8 heiQ domains: health-directed behaviour (relative risk [RR] 1.71, 95% confidence interval [CI] 1.13 to 2.59), emotional well-being (RR 1.73, 95% CI 1.07 to 2.79), self-monitoring and insight (RR 2.40, 95% CI 1.19 to 4.86), constructive attitudes and approaches (RR 2.40, 95% CI 1.37 to 4.21), skill and technique acquisition (RR 1.70, 95% CI 1.14 to 2.53), and health service navigation (RR 1.93, 95% CI 1.08 to 3.47). Improvement was also observed in the Physical Component Summary (p = 0.017) and the Single Index (p = 0.041) of the 12-Item Short Form Health Survey (version 2). The intervention group improved in fruit and vegetable consumption (odds ratio [OR] 2.36, 95% CI 1.41 to 3.95) and physical activity (OR 3.81, 95% CI 1.65 to 8.76). One-year improvement was maintained in the intervention group for several outcomes.Interpretation: It is possible to implement an intervention integrating chronic disease prevention and management services into primary care settings. We obtained positive and promising results using this intervention.

Integration of chronic disease prevention and management services into primary care (PR1MaC): findings from an embedded qualitative study

“…The details of the participants are described in the Table 1. Patients with multimorbidity defined as 3 chronic conditions or more, were predominantly represented in this study which is consistent with the participants of the trial [4]. Mean age of the patients was 58 in they had a mean of 5.9 chonic conditions.…”

“…All patient encounters were on a one-to-one and face-to-face basis. Details on the intervention are provided elsewhere and summarized in the Additional file 1 [3, 4].…”

“…PR1MaC encompassed a pragmatic randomized trial with a delayed intervention group to evaluate the quantitative effects of CDPM services on patients, and a qualitative evaluation of the intervention. In the pragmatic randomized trial [4], the intervention was associated with several improvements for patients: adoption of healthy lifestyle (increased fruit and vegetable consumption, increase in physical exercise), improved emotional well-being, improved self-management and improved knowledge about the management of chronic conditions. A total of 326 patients participated to the trial.…”

The impact of chronic disease management on primary care doctors in Switzerland: a qualitative study

“…This should include care coordination as a cornerstone of this effective team and be led by either the primary care practitioner or a trained case manager [ 35 – 37 ]. Prevention must become a top-priority [ 38 ] and must be financially rewarded [ 39 ]. Well-being and resilience promotion [ 40 , 41 ] should be a part of medical training to build emotional coping abilities [ 42 ].…”

Effectiveness of a chronic disease self-management program in Mexico: A randomized controlled study

“…Conversely, studies show that chronic disease prevention and treatments are more effective in integrated care models, which emphasize an active collaboration between patients and health professionals. [9][10][11] In addition, extensive research in the past 20 years indicate CDSMP programs are effective in improving health and reducing hospitalizations and emergency room use. [12] A meta-analysis and systematic literature review indicate that CDSMP programs are effective in reducing risk factors among patients with cerebrovascular disease.…”