The Effect of Chronic Care Model Based Education on Disease Management in Hypertensive Patients
Condition: Hypertension
MeSH terms: Hypertension
Study type: Interventional

Summary: 
      Background: This study was conducted to examine the effect of planned educational
      intervention based on The Chronic Care Model (CCM) on the management of hypertension in
      patients with hypertension. The Chronic Care Model is a framework for organizing and
      improving chronic illness care, based on a proactive, planned approach that incorporates
      patient self-care, provider, and system level interventions. Several instruments have been
      developed to evaluate the effects of CCM implementation on care and treatment outcomes.The
      Patient Assessment of Chronic Illness Care (PACIC) questionnaire is used in instrument to
      evalate the delivery of care for patients.

      Methods: The study was performed a prospective and conducted with a controlled
      semi-experimental pattern in matched groups. 30 patients including 15 intervention and 15
      control group patients matched in terms of socio-demographic features were monitored for six
      months. The intervention group was trained and monitored by a professional team in line with
      the components of the model. Life quality scale, hypertension information questions and
      chronic care assessment scale were applied to both groups at the beginning and in the sixth
      month of the study.

      Trial registration: The study was conducted in accordance with the World Medical Association
      Declaration of Helsinki of 1964, and approved by local authorities and local Bioethics
      Committees(BC) in participating university hospital. (Ethics committee approval
      No:B.30.2.EGE.0.20.05.00/OY/649/268 Decision No: 13-3.3/12) Permissions for the use of scale
      of PACIC and model of CCM were taken via e-mail.

      Key Words: nursing; chronic care model; hypertension
    

Detailed description: 
      According to the World Health Organisation, 60% of all deaths in the world result from
      chronic illnesses, and 80% of these deaths occur in low and middle income countries (WHO
      2008a).One of the most common chronic illnesses is hypertension, and it affects almost 20% of
      the adult population. The fact that chronic diseases have become widespread nowadays reveals
      the importance of chronic disease control and community-based disease management programs
      (Cranston 2006). Chronic disease management includes the treatment of the disease and
      preparing and strengthening the patients to help patients to gain self-management skills.
      With an effective disease management; symptoms, recourses to emergency units and
      hospitalisation can be reduced, physiological and psychological effects of the disease can be
      limited, dependence can be prevented, and life quality can be enhanced (Haskett 2006). Among
      the models of chronic disease management, the most well-known, the most frequently used and
      the most effective one is "Chronic Care Model"(CCM) (Piat et al. 2007). Since social and
      economic burden has gradually increased in chronic care management, "CCM" was presented as a
      guide with the aim of enhancing the quality of the care and reducing the care costs (Geyman
      2007). The main point of the model identified by Wagner et al. is the "existence of a
      fruitful interaction between the health care team and the patient" (Rothman & Wagner 2003,
      Solberg et al. 2005). According to the model, the "patient" motivated by a relation of
      knowledge, skill and trust and the "health care team" having the necessary expertise,
      knowledge and sources can take effective decisions for a high quality care and conduct an
      effective chronic disease care management by using the available sources (ICN 2010, Wagner
      2001). This research was conducted to evaluate the effects of the use of the CCM in patients
      with hypertension on life quality and clinic results and to conduct a study concerning the
      use of this model in the chronic diseases in Turkey.

      METHODS Research Design:The research was conducted in the nephrology polyclinic of a
      university hospital for six months with a controlled semi-experimental design in matched
      groups.

      Population and sample:Population of the research consisted of all patients who applied to and
      followed in the nephrology polyclinic. In the selection of the sample, patient files were
      listed by using the polyclinic records. Out of this list,2 groups were created as
      intervention and control group matched in consideration of socio-economic variables such as
      age, sex and educational background. According to the power-analysis method, 15 intervention
      and 15 control group patients constituted the sample of the research. The power of the study
      was determined as 90% in p=0,05 reliability coefficient .

      Data collection tools:In collecting the data, researcher used the socio-demographic features
      form prepared in consideration of the literature and expert views and the following forms for
      follow-up.

      Attitude and habits scale concerning hypertension Information about hypertension
      WHOQOL-BREF(Tr) life quality assessment scale Chronic Disease Care Assessment Scale (PACIC)
      Hospital Anxiety and Depression Scale Integration of CCM into the study I. Organization of
      Health Care

        1. Multidisciplinary Team and Duties and Responsibilities Multidisciplinary team consisted
           of internal medicine specialist, internal medicine specialist nurse, dietician and
           psychologist. Consultation was required from the other areas of specialisation when
           needed.

           Team Members (Primary Care Team): Internal medicine specialist carried out the physical
           examinations and system diagnosis of the patients to be included in the study,
           determined the laboratory requests and assessed the monthly patient data and shared the
           results with the team. The internal medicine specialist nurse collected and assessed the
           data, planned and executed the training, arranged weekly interviews and monthly controls
           and assessed the data. The psychiatrist assessed the suitability of the patients to the
           study, assessed the patients having adaptation problems with respect to lifestyle
           changes in monthly controls and also played roles in teaching the coping methods to
           patients and applying and interpreting the hospital anxiety and depression scale.
           Dietician planned the diet programs together with the patients and determined the
           calorie needs of diet programs.

        2. Identification of Objectives and Expected Results:

      The objectives of this study were determined in line with the following points that are
      considered to have impact on the success of the disease management:

      i.Since hypertension is a chronic disease, its management requires a long and effective time.

      ii.In the management of hypertension, patient is prioritised, not the disease. It requires a
      multidisciplinary teamwork with the patient, and team members need to work in an effective
      and cooperative manner.

      iii.It is important to determine the lifestyle and habits ofthe patient in the treatment of
      hypertension. Each patient diagnosed with hypertension display different behaviours and thus,
      different approaches might be needed for each patient.

      iv.Care and follow-up plans should be developed by determining the compliance/incompliance of
      patients to treatment and lifestyle changes, and the trust of the patient to care and
      treatment team is important in compliance to disease.

      v.Health education should be constant and accessible in hypertension; behavioural change
      takes time and therefore, it requires follow-up and motivation.

      vi.Patient education is planned in consideration of the faith and cultural values of the
      patient.

      c.Metabolic Control Variables were determined as fasting plasma glucose, serum total
      cholesterol, Serum LDL-cholesterol, Serum HDL- cholesterol, fasting serum triglycerides,
      HbA1C, spot urine, Glomerular filtration rate, ECG, height, weight, waist circumference and
      BMI.

      At the end of the study where the above mentioned points were addressed, it was expected that
      the patients could implement the lifestyle changes, could be effective in disease management,
      improvements would be observed in metabolic indicators related to the disease, adaptation of
      patients to disease and treatment and patients' life qualities would be improved, and
      patients' perspectives to the healthcare team would change.

      II.Self-management support: A training manual was prepared for information about the disease
      while PowerPoint presentations were prepared for individual trainings. Data collection forms
      were applied to determine the factors affecting compliance with the treatment, and data were
      shared with the patients.

      Training manual, PowerPoint presentation and web education page Socio-Demographic Features
      Data Form Metabolic values form Form for assessing the attitude and habits related to
      hypertension Information about hypertension WHOQOL-BREF(Tr) quality of life assessment form
      Patient Assessment of Chronic Illness Care (PACIC) Hospital Anxiety and Depression Scale
      III.Delivery System Design In both control and intervention groups, data forms were filled
      out at the beginning (0th month) and at the end (6. month) of the study. An intermediate
      control was carried out in the 3rd month for metabolic values. For the patients in the
      intervention group, trainings planned for lifestyle changes and disease management were
      delivered. No training was provided to the control group.However, at the end of the study,
      all trainings and information were provided to the patients in the control group.During
      preparation, a web page was designed to start the web-based training to the patients in the
      intervention group through internet connection from intervention group houses. In the
      hospital where the study was conducted, a database which could be accessed only with a
      personal password and the team members followed the patients through this database.Tension
      measuring training was provided to the patients in the intervention group by using 5A method
      so that the follow-up form could be used at home.

      Through phone calls, patients were encouraged to comply with the program. Situations
      preventing the compliance of patients and solution proposals were discussed. Activities which
      will enable participants to use their social supports effectively were discussed, as well.
      Calls were made by the researcher in charge and recorded in the patient database IV. Decision
      Support: Evidence-based manuals were used in the patient and patient relative training.
      Turkish Society of Cardiology National Hypertension Treatment and Follow-up Manual (2000),
      Turkish Society of Cardiology Nursing Care Manual for Heart Failure, Acute Coronary Syndromes
      and Hypertension (2007), European Society of Cardiology (ESC) Arterial Hypertension Treatment
      Manual 2007, Pulmonary Hypertension Diagnosis and Treatment Manual (2009), ACC/AHA
      Hypertension in the Aged Manual (2011), WHO-ISH (World Health Organisation/International
      Society for Hypertension 2003 Manual, JNC-7 2003 (Joint Committee 7th Report- USA
      Hypertension Manual), Turkish Society of Hypertension and Renal Diseases, Hipder TRNC
      Hypertension Society, webpage of the Ministry of Health Public Health Institution of
      Turkey,Information manual, Web-based training (www.ygulbin.com).

      V.Clinical Information Systems: An electronic patient file was created for each patient
      included in the study in the database taken from the data processing centre of the hospital
      (In this e-file, demographic characteristics of the patient, data collection tools used in
      the study and the data results, cardiovascular risk table, appointment dates, phone call
      results, patient assessment section reserved for each team member, consultation results,
      urgent and immediate intervention situations emerging during the study, comorbidity record
      are included). The database explained above can be accessed only through a password so that
      only team members can have access to data, interference in the study data is prevented, and
      patient privacy and confidentiality are protected as the ethical dimension of the study.

      VI.Social resources and policies: Exercise programs: In line with the address information of
      the intervention patients, purpose/content of the study was discussed with the gyms of
      municipalities and patients were made to benefit from these facilities for free. For the
      patients preferring private gyms, it was ensured that discounts were made for the patients.

      Statistical Analysis In the statistical analysis of the data, number and percentage
      distribution, significance test of the difference between two pairs (t test), significance
      test of the difference between two means (t test), one way variance analysis (ANOVA),
      chi-square test and Mann-Whitney U test, General Linear Model - repeated measures define
      Factor(s) at repeated measurements were used through Statistical Package for Social Sciences
      for Windows Version 18.0 software. Statistical analyses were carried out by a biostatistics
      expert.

      Ethical Consents:Written and verbal consents were received from the patients for conducting
      the research.Ethics committee approval No:B.30.2.EGE.0.20.05.00/OY/649/268 Decision No:
      13-3.3/12) was received from the institution where the study was conducted. Permissions for
      the use of scales and model were taken via e-mail. As ethical responsibility, the same
      training, training materials and exercise opportunities were provided to the patients in the
      control group at the end of the research. Since blood and urine tests and other examinations
      to be used in the study were performed in the polyclinics where patients received service
      during their routine controls, the patient or researcher was not charged a fee.
    

Intervention name(s): control by dietitian; Exercise programs; control by psychiatrist
Intervention type(s): Dietary Supplement; Other; Behavioral
Intervention description(s): In line with the address information of the intervention patients, purpose/content of the study was discussed with the gyms of municipalities and patients were made to benefit from these facilities for free. For the patients preferring private gyms, it was ensured that discounts were made for the patients.; The psychiatrist assessed the suitability of the patients to the study, assessed the patients having adaptation problems with respect to lifestyle changes in monthly controls and also played roles in teaching the coping methods to patients and applying and interpreting the hospital anxiety and depression scale.
Other intervention name(s): behavioral
Allocation: Randomized
Intervention model: Crossover Assignment
Intervention model description: controlled semi-experimental design in matched groups
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: nursing; chronic care model; hypertension