Chronic disease management
Conditions
Interventions
Care management delivered by teams of primary care physicians and trained health care assistants compared to usual care. Care management consists of comprehensive assessment of medical and non-medical
Sponsors
University Hospital Heidelberg (Germany)
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: 1. Adults (18 years+) with any of the following index conditions and a high predicted likelihood of hospitalisation based on insurance claims data analysis: 1.1. Type 2 diabetes 1.2. Chronic obstructive pulmonary disease 1.3. Chronic heart failure 2. Beneficiaries of a GP-centred care contract of the General Regional Health Fund (AOK) 3. Listed in one of the participating practices
Exclusion criteria
Exclusion criteria: 1. Active cancer disease (under ongoing radio- or chemotherapy) 2. Undergoing dialysis 3. Moderate to severe dementia 4. Concurrent participation in other clinical trials 5. Living in nursing homes 6. Physical, mental or other conditions that hinder active participaton in the trial
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Number of all-cause hospitalisations within 12 months of intervention/control | — |
Secondary
| Measure | Time frame |
|---|---|
| 1. Health related quality of life (SF-12, EQ5D) 2. Medication adherence 3. Self-management 4. Patient reported delivery of chronic care elements (PACIC) 5. Health care costs 6. Contacts with specialists/generalists and supportive services 7. Mortality 8. Clinical status 9. Depression All outcomes will be assessed at 12 and 24 months. | — |
Countries
Germany
Outcome results
None listed