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

Abstract

BackgroundThe 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.MethodThe 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.ResultsWe 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.ConclusionThe 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 registrationClinicalTrials.gov: NCT01297075

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

“… 42 60–67 131 132 Of the 63 intervention studies, 24 identified training facilitators. 32 37 46–48 68 69 102–107 118–120 129 133–139 Seventeen of these 24 studies described training components, with nine studies including length of training, ranging from 4 hours, 107 40 hours, 118 1–3 days 68 102 137–139 to 6–7.5 months. 32 106 Training components typically included course work (theoretical knowledge), 37 47 102 119 120 or both course work and practical experience (skills training).…”

Stepped wedge cluster randomised trials: a review of the statistical methodology used and available

“…Whilst it is not clear if this is due to a lack of agreement on how to analyse the data from a SWD or because of the variety of applications of the SWD or some combination of the two, the majority of studies chose to adjust for the longitudinal nature of the SWD with either GLMMs ( n = 60, 59 %) or GEEs ( n = 17, 17 %). The remainder used a variety of methods including generalised linear models (GLM) with robust variance estimators [ 46 – 48 ], Cox proportional hazards modelling [ 26 , 49 – 52 ], paired t-tests [ 53 , 54 ], χ 2 tests [ 54 , 55 ], McNemar’s test [ 56 ], Wilcoxon rank sum test/Mann-Whitney U test [ 57 , 58 ], Analysis of covariance (ANCOVA) [ 58 , 59 ], Analysis of variance (ANOVA) [ 60 ], Discourse mapping [ 61 ], GLM’s with cluster as a fixed effect [ 62 – 70 ] and GLM’s without any reported effort to adjust for clustering [ 71 – 75 ]. For some studies the method of analysis was unclear [ 14 , 76 – 79 ].…”

Asthma dissemination around patient-centered treatments in North Carolina (ADAPT-NC): a cluster randomized control trial evaluating dissemination of an evidence-based shared decision-making intervention for asthma management

“…However, other pragmatic approaches to disseminate complex interventions through different levels of practice facilitation have shown mixed results. In one study of chronic care model implementation, continuous quality improvement and reflective adaption resulted in improved outcomes for all arms [30], while another stepped wedge study disseminating a chronic care model for diabetes and COPD indicated mixed results that were difficult to distinguish from concurrent initiatives [31]. A consistent result across many of these studies, including the ADAPT-NC Study, showed that patient perceptions of improved decision-making outcomes associated with the intervention were statistically significant however, significant improvements in disease outcomes between arms were harder to detect.…”

“…While practice facilitation interventions may increase time and intensity, they add value by building relationships, improving communication, fostering change, and sharing resources [32]. Practice facilitators partner with their practices to help them introduce and sustain organizational change, thereby addressing the challenges associated with implementing evidence-based guidelines into practice, a skill many practices struggle to achieve independently [31].…”