Outreach Visits to Optimize Chronic Care Management in General Practice: A Cluster Randomized Trial

Study Overview
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Brief Summary
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The aim of this project is to motivate and support general practice clinics in implementing the visions and recommendations presented in two of the disease specific programmes for chronic care management (for chronic obstructive lung disease and Type 2 diabetes). These programmes describe evidence based treatment and division of tasks between the municipalities, the hospitals and general practice. The Facilitator Project is funded by The Danish Ministry of Interior and Health.

Detailed Description
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In a cluster randomized trial the investigators will explore the efficacy of up to three outreach visits by specially trained GPs. Efficacy data are obtained by means of questionnaires at regional databases.

Official Title
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Outreach Visits to Optimize Chronic Care Management in General Practice: A Cluster Randomized Trial

Conditions
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Chronic Disease

Intervention / Treatment
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* Behavioral: Outreach visits


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: General Practices working in the capital region in Denmark Exclusion Criteria: General Practices where the facilitator works.

Ages Eligible for Study
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Minimum Age: 30 Years
Maximum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Outreach visits<br>Practices allocated to outreach visits may receive up to three outreach visits in order to motivate and support general practice clinics in implementing two chronic care programmes for chronic obstructive Pulmonary disease and Type 2 diabetes. | Behavioral: Outreach visits<br>* The 16 facilitators in the project attend an educational programme designed to provide them with the necessary skills and tools for the task. The facilitators visit general practice clinics from March 2011 until the end of 2012. Each clinic is offered three visits. The facilitator is to act as a change agent who motivates and helps the clinic team in the process of defining common goals, and choosing the appropriate means for achieving them.<br>|
| No Intervention: Control (late intervention)<br>These practices are allocated to outreach visits after the initial evaluation stops at 12 months. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from baseline at 12 month in Annual systematic chronic disease follow up consultations | Change in annual systematic chronic disease controls per person affiliated with a primary care at a period at baseline and at 12 month. | Month 4, 3, 2 before baseline and month 13,14,15 after baseline (after intervention) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| ICPC diagnosis coding | Self reports regarding the use of ICPC diagnosis coding for Type 2 Diabetes and Chronic Obstructive Pulmonary Disease. | 12 months | 
| Sentinel Data Capture | Application for the electronic Sentinel Data Capture module for overview of patients with chronic diseases. | 12 months | 
| Stratification | The self reported use of stratification as part of primary care management of patients with chronic diseases | 12 months | 
| Change from baseline and at 12 month in practices with low performance on annual systematic chronic disease follow up consultations. | Reduction in the number of practices with less than 1% annual systematic chronic disease follow up consultations. | Month 4, 3, 2 before baseline and month 13,14,15 after baseline (after intervention) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Health Services Research, Chronic Care, Outreach Visits, Primary care, chronic disease management