Chronic diseases
Conditions
Interventions
Group 1: The intervention group (IG) consists of the recruited patients from the expected 20 participating general practices. The following interventions are implemented in the participating practices
gesundheitliche Versorgungsleistungen) beyond the existing standard of care thereby enabling intensified coordination of care and case management
- Optional provision of the SmED system (Structured Me
Sponsors
Kassenärztliche Vereinigung Baden-Württemberg
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Inclusion criteria
Inclusion criteria: - At least one life-altering chronic condition (billing of the chronic care lump-sum fees of the German Uniform Value Scale (EBM; GOP 03220, 03221) in at least two of the last four quarters by participating general practices; analogous criteria apply for patients enrolled in GP-centered care schemes). - Continuous treatment in the participating general practice for at least four quarters prior to the inclusion quarter. - Patients in an unstable phase of chronic disease (with ambulatory care–sensitive emergencies related to their chronic condition and/or hospitalizations due to their chronic condition within the past three years). - Patients in a stable phase of chronic disease with a high risk of decompensation. To identify potential participants, the following set of criteria was defined for general practitioners/practice teams: • Hospitalizations/ambulatory care–sensitive emergencies in the preceding three years • Geriatric multimorbidity (defined by the presence of the following criteria: immobility; cognitive impairment; severe visual impairment; significant hearing loss; depression/anxiety disorder; propensity to falls and dizziness; chronic pain, sensory disturbances, reduced medication tolerance; incontinence; fluid and electrolyte imbalance; pressure ulcers; malnutrition or undernutrition; reduced physical resilience/frailty) • Unfavorable home or family situation (e.g., living alone, partner also in need of care, no relatives in close proximity) • Presence of an assigned care level • (Increasing) medication dose escalation (frequent dose increases/changes in the medication regimen) • Increasing number of acute exacerbations of the underlying condition(s), changes in vital parameters such as blood pressure, heart rate, or oxygen saturation indicating progression of one or more underlying diseases • (Unplanned) weight changes (gain or loss, particularly in patients with heart failure or chronic obstructive pulmonary disease) • Indications of limited ability to cooperate/adherence to treatment
Exclusion criteria
Exclusion criteria: - Patients whose estimated life expectancy at the start of the intervention is less than four quarters (minimum intervention period). Palliative care patients are eligible provided they meet the inclusion criteria and their estimated life expectancy exceeds four quarters - Practices that are already participating in similar studies
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Number of ambulatory-sensitive emergencies (ASEs) after 12 months, identified via billing codes (GOP) | — |
Secondary
| Measure | Time frame |
|---|---|
| The following endpoints are captured using routine data from the Association of Statutory Health Insurance Physicians of Baden-Württemberg (Kassenärztliche Vereinigung Baden-Württemberg, KVBW). Endpoints without a specified time frame are measured over the entire intervention period: - Number of ambulatory-sensitive emergencies (ASE) per person-year (GOP, taking into account the patient-specific intervention period) - Proportion of patients with at least one ASE after 12 months (GOP) - Number of ambulatory emergencies (diagnosis-independent) after 12 months (GOP) - Number of ambulatory emergencies (diagnosis-independent) per person-year (GOP, taking into account the patient-specific intervention period) - Utilization of outpatient care: number contacts with general practitioner (GP; number of quarters with visits to GP), number of contacts with other specialist (number of quarters with visits to other specialist) - Treatment intensity and productivity: average EBM points per patient, number of cases per practice, average EBM points per practice - Continuity of care: Continuity-of-Care Index (e.g. Bice-Boxerman Index) - Coordination of care: number of GPs consulted per patient; number of other specialists consulted per patient; proportion of visits to other specialists with referral - Preventive services: vaccination rates (e.g., influenza, pneumococcal, COVID-19) - Outpatient care costs: cumulative outpatient care costs from billing data after 12 months, as well as intervention costs - Outpatient cost-effectiveness The following endpoints are captured using routine data from AOK Baden-Württemberg (AOK BW). Endpoints without a specified time frame are measured over the entire intervention period: - Combined number of ASE and ambulatory-sensitive hospitalizations after 12 months - Combined number of ASE and ambulatory-sensitive hospitalizations per person-year - Combined number of ambulatory and inpatient emergencies (diagnosis-independent) after 12 mo | — |
Countries
Germany
Contacts
Public ContactLeonie Sundmacher
Technische Universität München
Outcome results
None listed