Case management and self-management support for frequent users with chronic disease in primary care: A pragmatic randomized controlled trial

BMC Health Services Research

Volumn 13, Issue 1, 2013, Pages

  Chouinard, Maud Christine ^a,b   Hudon, Catherine ^b,c   Dubois, Marie France ^c   Roberge, Pasquale ^c   Loignon, Christine ^c   Tchouaket, Éric ^d   Fortin, Martin ^b,c   Couture, Éva Marjorie ^b   Sasseville, Maxime ^c  

^a UNIVERSITÉ DU QUÉBEC À CHICOUTIMI   (Canada)

^b Centre de Santé et de Services Sociaux de Chicoutimi   (Canada)

^c UNIVERSITÉ DE SHERBROOKE   (Canada)

^d UNIVERSITÉ DU QUÉBEC EN OUTAOUAIS   (Canada)

Author keywords

Case management; Chronic diseases; Family Medicine Group; Frequent users; Primary care; Primary care nursing; Self management; Services integration

Indexed keywords

ARTICLE; CANADA; CASE MANAGEMENT; CHRONIC DISEASE; CONTROLLED CLINICAL TRIAL; CONTROLLED STUDY; COST BENEFIT ANALYSIS; ECONOMICS; HOSPITAL; HUMAN; INTEGRATED HEALTH CARE SYSTEM; PRIMARY HEALTH CARE; QUALITATIVE RESEARCH; RANDOMIZED CONTROLLED TRIAL; SELF CARE; SOCIAL SUPPORT; THEORETICAL MODEL; UTILIZATION REVIEW;

CASE MANAGEMENT; CHRONIC DISEASE; COST-BENEFIT ANALYSIS; DELIVERY OF HEALTH CARE, INTEGRATED; HOSPITALS; HUMANS; MODELS, THEORETICAL; PRIMARY HEALTH CARE; QUALITATIVE RESEARCH; QUEBEC; SELF CARE; SOCIAL SUPPORT;

MLCS; MLOWN;

EID: 84873383217     PISSN: None     EISSN: 14726963     Source Type: Journal    
DOI: 10.1186/1472-6963-13-49     Document Type: Article

References (79)

1. Commissaire à la santé et au bien-être du Québec, Rapport d'appréciation de la performance du système de santé et de services sociaux 2010: État de situation portant sur les maladies chroniques et la réponse du système de santé et de services sociaux Montréal: Gouvernement du Québec 2010 23449575
2. Organisation mondiale de la santé Innovative care for chronic conditions-Building blocks for action: Global report Genève: World Health Organization 2002
3. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part II). Marks R, Allegrante JP, Lorig K, Health Promot Pract 2005 6 2 148 156 10.1177/1524839904266792 15855284
4. Lifting the burden of chronic disease: What has worked? What hasn't? What's next? Kreindler SA, Healthc Q 2009 12 2 30 40 19458507
5. Departement of Health, Supporting People with Long Term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration UK: 2005
6. Self-management perspectives of heavily comorbid primary care adults. Corser W, Dontje K, Prof Case Manage 2011 16 1 6 17
7. MSSS, Stratégie de prévention et de gestion des maladies chroniques et Plan d'action 2008-2013 Québec: Ministère de la santé et des services sociaux 2008 23474357
8. McMurphy D, Quels sont les caractéristiques et les avantages fondamentaux de services de santé de première ligne de qualité ? Ottawa: FCRSS 2009
9. Singh D, Transforming chronic care: Evidence about improving care for people with long-term conditions Birmingham, UK: University of Birmingham & NHS Institue for innovation and improvement 2005
10. A population-based study of the association between socioeconomic status and emergency department utilization in Ontario, Canada. Khan Y, Glazier RH, Moineddin R, Schull MJ, Acad Emerg Med 2011 18 8 836 843 10.1111/j.1553-2712. 2011.01127.x 21843219
11. Socio-economic status and rates of hospital admission for chronic disease in urban Canada. Disano J, Goulet J, Muhajarine N, Neudorf C, Harvey J, Can Nurse 2010 106 1 24 29 21066952
12. Depression and comorbid illness in elderly primary care patients: Impact on multiple domains of health status and well-being. Noël PH, Williams JW Jr, Unützer J, Worchel J, Lee S, Cornell J, Katon W, Harpole LH, Hunkeler E, Ann Fam Med 2004 2 6 555 562 10.1370/afm.143 15576541 (Pubitemid 39643430)
13. Predictors of the quality of life of older people with heart failure recruited from primary care. Gott M, Barnes S, Parker C, Payne S, Seamark D, Gariballa S, Small N, Age Ageing 2006 35 2 172 177 10.1093/ageing/afj040 16495294
14. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Walker AE, Chronic Illn 2007 3 3 202 218 10.1177/1742395307081504 18083677 (Pubitemid 351927861)
15. High health care utilization and costs associated with lower socio-economic status: results from a linked dataset. Lemstra M, Mackenbach J, Neudorf C, Nannapaneni U, Can J Public Health 2009 100 3 180 183 19507718
16. Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. Bieler G, Paroz S, Faouzi M, Trueb L, Vaucher P, Althaus F, Daeppen J-B, Bodenmann P, Acad Emerg Med 2012 19 1 63 68 10.1111/j.1553-2712.2011.01246.x 22221292
17. Effectiveness of interventions targeting frequent users of emergency departments: a systematic review. Althaus F, Paroz S, Hugli O, Ghali WA, Daeppen JB, Peytremann-Bridevaux I, Bodenmann P, Ann Emerg Med 2011 58 1 41 52 e42 10.1016/j.annemergmed.2011.03.007 21689565
18. Beaulieu MD, Denis JL, D'Amour D, Goudreau J, Haggerty J, Hudon E, Jobin G, Lamothe L, Gilbert F, Guay H, L'implantation des Groupes de médecine de famille: Un défi de la réorganisation de la pratique et de la collaboration interprofessionnelle. Étude de cas dans cinq GMF de la première vague au Québec Ottawa: FCRSS 2006 23495114
19. Family Medicine Groups http://www.msss.gouv.qc.ca/en/sujets/organisation/ gmf.php
20. du Québec G, Évaluation de l'implantation et des effets des premiers groupes de médecine de famille au Québec Québec: Direction des communications du ministère de la Santé et des Services sociaux du Québec 2009
21. Referring patients with complex problems to community matrons. Lawlor P, Prim Health Care 2009 19 10 22 24
22. Chouinard MC, Fortin M, Tremblay S, Table ronde sur les maladies chroniques au Saguenay Saguenay-Lac-Saint-Jean: Constats et recommandations Chicoutimi: Agence de santé et de services sociaux du Saguenay-Lac-Saint-Jean 2011
23. Department of Health, Caring for people with long term conditions: An education framework for community matrons and case managers UK: Department of Health-Long term conditions team 2006
24. Bilodeau MN, Programme Arrimage: Rapport d'activités Chicoutimi: CSSS de Chicoutimi 2011
25. Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people. Schraeder C, Fraser CW, Clark I, Long B, Shelton P, Waldschmidt V, Kucera CL, Lanker WK, J Nurs Healthc Chronic Illn 2008 17 11C 407 417
26. Structured review: Evaluating the effectiveness of nurse case managers in improving health outcomes in three major chronic diseases. Sutherland D, Hayter M, J Clin Nurs 2009 18 21 2978 2992 10.1111/j.1365-2702.2009.02900.x 19747197
27. Kendall S, Wilson P, Procter S, Brooks F, Bunn F, Gage H, McNeilly E, The nursing contribution to chronic disease management: A whole systems approach Hatfield, UK: Queen's Printer and Controller of HMSO 2010
28. Santé Canada, Fond pour l'adaptation des soins de santé primaires: Résumé des initiatives Ottawa: Gouvernement du Canada 2007
29. Zwar N, Harris M, Griffiths R, Roland M, Dennis S, Powell Davies G, A systematic review of chronic disease management Canberra: Australian Primary Health Care Research Institute 2006
30. Improving patient care. Meta-analysis: Chronic disease self-management programs for older adults. Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, Rhodes S, Shekelle P, Ann Intern Med 2005 143 6 427 438 16172441
31. Commissaire à la santé et au bien-être du Québec, Rapport d'appréciation de la performance du système de santé et de services sociaux 2009. Construire sur les bases d'une première ligne de soins renouvelée: Recommandations, enjeux et implications Montréal: Gouvernement du Québec 2009 23449575
32. Rehabilitation in primary care setting for persons with chronic illness: A randomized controlled trial. Richardson J, Letts L, Chan D, Stratford P, Hand C, Price D, Hilts L, Coman L, Edwards M, Baptiste S, Prim Health Care Res Dev 2010 11 382 395 10.1017/S1463423610000113
33. Self-management support and training for patients with chronic and complex conditions improves health-related behaviour and health outcomes. Harvey PW, Petkov JN, Misan G, Fuller J, Battersby MW, Cayetano TN, Warren K, Holmes P, Aust Health Rev 2008 32 2 330 338 10.1071/AH080330 18447824
34. How effective are the linkages between self-management programmes and primary care providers, especially for disadvantaged patients? Williams AM, Dennis S, Harris MF, Chronic Illn 2010 7 1 20 30 20921035
35. Innovations in primary care. Patient self-management of chronic disease in primary care. Bodenheimer T, Lorig K, Holman H, Grumbach K, JAMA 2002 288 19 2469 2475 10.1001/jama.288.19.2469 12435261 (Pubitemid 35340544)
36. Kaiser Permanente: Integrating around a care delivery model. Slaughter J, J Ambulatory Care Manage 2000 23 3 39 47 11184894 (Pubitemid 30437628)
37. National Health Service, Improving the care for people with long-term conditions Birmingham, UK: University of Birmingham 2006
38. Enabling the implementation of evidence based practice: A conceptual framework. Kitson A, Harvey G, McCormack B, Qual Health Care 1998 7 3 149 158 10.1136/qshc.7.3.149 10185141
39. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A, Implementation Sci: IS 2008 3 1 1 10.1186/1748-5908-3-1
40. American Nurses Association, Nursing's social policy statement Silver Spring: MD: ANA 2010 23495194
41. Primary care practice-based care management for chronically ill patients (PraCMan): study protocol for a cluster randomized controlled trial [ISRCTN56104508]. Freund T, Peters-Klimm F, Rochon J, Mahler C, Gensichen J, Erler A, Beyer M, Baldauf A, Gerlach FM, Szecsenyi J, Trials 2011 12 163 163 10.1186/1745-6215-12-163 21714883
42. A quality improvement tool to assess self-management support in primary care. Brownson CA, Miller D, Crespo R, Neuner S, Thompson J, Wall JC, Emont S, Fazzone P, Fisher EB, Glasgow RE, Joint Comm J Qual Patient Saf 2007 33 7 408 416
43. Clinical governance in primary care: A literature review. Tait AR, J Clin Nurs 2004 13 6 723 730 10.1111/j.1365-2702.2004.00949.x 15317512 (Pubitemid 39237004)
44. The patient's voice: an exploratory study of the impact of a group self-management support program. Johnston S, Irving H, Mill K, Rowan MS, Liddy C, BMC Fam Pract 2012 13 1 65 72 10.1186/1471-2296-13-65 22748018
45. L'évaluation dans le domaine de la santé: Concepts et méthodes. Champagne F, Contandriopoulos A, Brousselle A, Hartz Z, Denis J, L'évaluation: Concepts et méthodes Montréal: PUM, Brousselle A, Champagne F, Contandriopoulos A, Hartz Z, 2009 35 56 23495114
46. Pawson R, Tilley N, Realistic evaluation London: Sage 1997
47. Designing an effective evaluation plan: a tool for understanding and planning evaluations for complex nursing contexts. Walsh K, Duke J, Foureur M, Macdonald L, Contemp Nurse 2007 25 1-2 136 145 17622997
48. Introduction générale à l'évaluation de programme. Ridde V, Dagenais C, Approches et pratiques en évaluation de programme Montréal: PUM, Ridde V, Dagenais C, 2009 11 29
49. Yin RK, Case study research: Design and methods Thousand Oaks, CA: Sage 2008
50. L'analyse de l'implantation. Champagne F, Brousselle A, Hartz Z, Contandriopoulos A, Denis J, L'évaluation: Concepts et méthodes Montréal: PUM, Brousselle A, Champagne F, Contandriopoulos A, Hartz Z, 2009 225 250 23495114
51. Realistic evaluation and case studies: Stretching the potential. Koenig G, Evaluation 2009 15 1 9 30 10.1177/1356389008097869
52. Intervention fidelity. Sidani S, Braden SJ, Design, evaluation, and translation of nursing interventions San Francisco, CA: John Wiley & Sons, Sidani S, Braden SJ, 2011 125 145
53. Gagnon YC, L'étude de cas comme méthode de recherche Québec: PUQ 2 2011 23495114
54. Lincoln YS, Guba E, Naturalistic enquiry Beverley Hills, CA: Sage 1985
55. Pragmatic clinical trials. MacPherson H, Complement Ther Med 2004 12 2-3 136 140 15561524
56. Fortin MF, Fondements et étapes du processus de recherche Montréal: Chenelière 2010 20348417
57. Identification of patients likely to benefit from care management programs. Freund T, Mahler C, Erler A, Gensichen J, Ose D, Szecsenyi J, Peters-Klimm F, Am J Manag Care 2011 17 5 345 352 21718082
58. Médiamed Technologies, Mesure de la performance: Logiciel MAGIC Chronique Mont-Saint-Hilaire, Québec: Médiamed Technologies
59. CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting parallel group randomised trials. Moher D, Hopewell S, Schulz KF, Montori V, Gøtzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG, J Clin Epidemiol 2010 63 8 1 e37 10.1016/j.jclinepi.2010.03.004 20346624
60. Development and evaluation of self-management interventions. Steed L, Mulligan K, Newman S, Chronic physical illness: Self-management and behavioral interventions Beckshire, UK: Open University Press, Newman S, Steed L, Mulligan K, 2009 135 147
61. Effect of a self-management program on patients with chronic disease. Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M, Eff Clin Pract 2001 4 6 256 262 11769298
62. The Health Education Impact Questionnaire (heiQ): An outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions. Osborne RH, Elsworth GR, Whitfield K, Patient Educ Couns 2007 66 2 192 201 10.1016/j.pec.2006.12.002 17320338 (Pubitemid 46575176)
63. The evaluation of chronic disease self-management support across settings: the international experience of the health education impact questionnaire quality monitoring system. Osborne RH, Batterham R, Livingston J, Nurs Clin North Am 2011 46 3 255 10.1016/j.cnur.2011.05.010 21791261
64. At the interface of community and healthcare systems: a longitudinal cohort study on evolving health and the impact of primary healthcare from the patient's perspective. Haggerty J, Fortin M, Beaulieu M-D, Hudon C, Loignon C, Préville M, Roberge D, BMC Health Serv Res 2010 10 258 258 10.1186/1472-6963-10-258 20815880
65. Psychometric properties of the patient activation measure among multimorbid older adults. Skolasky RL, Green AF, Scharfstein D, Boult C, Reider L, Wegener ST, Health Serv Res 2011 46 2 457 478 10.1111/j.1475-6773.2010.01210. x 21091470
66. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SLT, Walters EE, Zaslavsky AM, Psychol Med 2002 32 6 959 976 10.1017/S0033291702006074 12214795
67. A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity. Ware J Jr, Kosinski M, Keller SD, Med Care 1996 34 3 220 233 10.1097/00005650-199603000-00003 8628042 (Pubitemid 126433231)
68. An empirical comparison of four generic health status measures. Essink-Bot ML, Krabbe PF, Bonsel GJ, Aaronson NK, Med Care 1997 35 5 522 537 10.1097/00005650-199705000-00008 9140339
69. Quick assessment of literacy in primary care: The newest vital sign. Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA, Ann Fam Med 2005 3 6 514 522 10.1370/afm.405 16338915 (Pubitemid 43154837)
70. The Hospital Anxiety and Depression Scale. Zigmond AS, Snaith RP, Acta Psychiatr Scand 1983 67 6 361 370 10.1111/j.1600-0447.1983.tb09716.x 6880820 (Pubitemid 13098606)
71. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. Bjelland I, Dahl AA, Haug TT, Neckelmann D, J Psychosom Res 2002 52 2 69 77 10.1016/S0022-3999(01)00296-3 11832252 (Pubitemid 34192886)
72. Subjective assessments of comorbidity correlate with quality of life health outcomes: initial validation of a comorbidity assessment instrument. Bayliss EA, Ellis JL, Steiner JF, Health Qual Life Outcomes 2005 3 51 51 10.1186/1477-7525-3-51 16137329 (Pubitemid 41522354)
73. Cohen J, Statistical power analysis for the behavioural sciences Illsdale, NJ: Academic Press 2 1988
74. Cochran WG, Sampling techniques New York: John Wiley & Sons 3 1977
75. Cost-effectiveness of clinical case management for ED frequent users: Results of a randomized trial. Shumway M, Boccellari A, O'Brien K, Okin RL, Am J Emerg Med 2008 26 2 155 164 10.1016/j.ajem.2007.04.021 18272094 (Pubitemid 351215789)
76. Evaluation of a rural chronic disease self-management program. Stone GR, Packer TL, Rural Remote Health 2010 10 1 10p
77. Drummond MF, Sculpher MJ, Torrance MJ, O'Brien BJ, Stoddart GL, Methods for the economic evaluation of health care programmes 3rd edn Toronto: Oxford University Press 2005
78. Cost-benefit analysis: an ethical critique. Kelman S, Regulation 1981 5 1 33 40 10309353
79. Economic valuation through cost-benefit analysis-possibilities and limitations. Hansjürgens B, Toxicology 2004 205 3 241 252 10.1016/j.tox.2004.06.054 15464633 (Pubitemid 39303793)