In total, 22 regional practice projects were developed, followed and evaluated within the framework of the ZonMw programme ‘Disease Management Chronische Ziekten’ (Evaluating disease-management programmes in chronic care; DMCZ). The duration of these ZonMw practice projects was approximately three years. During this period the projects were systematically monitored on a number of process- and effect outcomes and cost-effectiveness. Disease-management programmes based on Ed Wagner’s chronic care model are expected to enhance quality of chronic care delivery. Insight into the short and long-term effects of implementation of this type of programme for different chronic conditions is still scarce, however. Questionnaires were sent in the years 2010, 2011 and 2012 to all patients and professionals involved in these 22 disease-management projects in the Netherlands. This survey shows that quality of chronic care delivery substantially improved over these years. Moreover, in the short term (after one year) patients exercised more and the number of smokers had decreased.
The long-term benefits of disease management programs based on the Chronic Care Model in the Netherlands include the successful improvement of chronically ill patients’ health behaviours and physical quality of life. However, these programs did not successfully improve or even maintain broader self-management abilities or mental quality of life, which declined over time. These findings highlight the need to focus on broader self-management abilities (self-efficacy, resource investment, initiative taking) and overall quality of life rather than physical functioning, disease limitations, and lifestyle behaviours alone, and to protect time for personal contact between patients and health care professionals to discuss concerns about dealing with chronic illness. Such contact is not interchangeable with e-consultation or the online exchange of information via a patient portal; it is a requirement for truly effective and productive interaction between chronically ill patients and teams of health care providers. The implementation of interventions that meet the needs of patients while enhancing their self-management abilities and making them proactive participants in their care delivery poses a challenge. Individuals’ ability to take care of them-selves as best and as long as possible is becoming increasingly important. Better self-management abilities can prevent worsening of a disease, allowing patients to maintain physical as well as mental quality of life and thereby relieving the pressure on the health care system caused by the increasing demand for care and support. Spending more time with chronically ill patients and attending to their broader needs may help them remain independent and healthy for a longer period of time and prevent use of more expensive health care.
This research clearly showed that disease management programs struggle to effectively reach chronically ill patients and train them to be effective coproducers (eg, informed, activated participants) in care delivery. As coproducers of chronic care, chronically ill people should be stimulated and made capable of managing their own health and quality of life. To obtain the best possible health gains with scarce public resources, preventive measures that enhance chronically ill patients’ commitment to their own health and support lifestyle improvements are increasingly needed. With regard to cost-effectiveness, there are no indications of care substitution from hospital care to the primary care sector. The disease-management programmes overall were not yet cost-effective after two years. Still, the individual programmes showed different cost-effectiveness outcomes.
Important factors for the development and implementation of the projects were the extent to which the required system changes had been anticipated and the level of flexibility to respond to the needs of health professionals and patients during the process. Improved communication and coordination between professionals appeared to be the major predictors for successful implementation of the practice projects. Communication is effective when it is frequent, timely, accurate and aimed at solving problems. Mutual respect, shared goals and shared knowledge are relational aspects essential for effective coordination. Care delivery to chronically ill patients requires optimal coordination between different types of professionals: general practitioners, primary care practice assistant, dietician, physiotherapist, occupational therapist, medical specialist, etcetera.
Only when Professionals of different backgrounds work well together they will be able to offer proper support to the chronically ill and thus improve quality of care.
Not unimportantly, the question was raised whether the disease management programmes would be sustained in practice after ZonMw funding was stopped. A selected number of programmes were therefore monitored one year longer, for the duration of 2013. The answer indeed appeared to be affirmative: improvements in quality of care, patients’ health behaviour and physical quality of life were sustained, although improvement in mental quality of life had not yet been achieved. The results also show that quality improvements both during the first year and the second year after implementation predict successful sustainment of the disease management programmes, as perceived by the health professionals involved. Likewise, results from the survey show that the patients on average perceive improved quality of care delivery. Still, professionals are aware of improvements in chronic care delivery at an earlier stage than are the patients; for example through complying with protocols, using a (Chain) ICT-system and establishing collaborations with other professionals. This perception appears to predict a more positive patient perception of quality of care delivery one year later. This finding emphasizes the importance of improvement in quality of care even if this has not yet had an impact on patients.
Of great importance in the care process is the role of the patients themselves. This is why the disease management programmes place a focus on self-management. Interventions aimed at self-management include lifestyle counselling, smoking cessation and exercise programmes and active involvement in drawing up a personal treatment plan. The effect was a lower percentage of smokers and more intense exercise after implementation of the disease management programme. In addition, patients’ physical quality of life improved on the longer term. On the other hand, mental quality of life declined both on the short term and the long term. Seeing that the self-management interventions notably were targeted to life style and physical quality of life, it would be worthwhile also to pay more attention in the future to the mental quality of life aspects of having to live with a chronic condition.
Publications from this project
Cramm, J.M., Nieboer, A.P. (2015). Disease Management: The Need for a Focus on Broader Self-Management Abilities and Quality of Life. Population Health Management. doi:10.1089/pop.2014.0120.
Cramm, J.M. & Nieboer, A.P. (2015). The importance of productive patient-professional interaction for the well-being of chronically ill patients. Quality of Life Research, 24 (4), 897-903. doi: http://dx.doi.org/10.1007/s11136-014-0813-6.
Cramm, J.M., Adams, S.A., Walters, B.H., Tsiachristas, A., Bal, R.A., Huijsman, R., Rutten - van Molken, M.P.M.H. & Nieboer, A.P. (2014). The role of disease management programs in the health behavior of chronically ill patients.Patient Education and Counseling. doi: http://dx.doi.org/10.1016/j.pec.2013.12.017.
Cramm, J.M., Tsiachristas, A., Adams, S.A., Walters, B.H., Bal, R.A., Huijsman, R. & Nieboer, A.P. (2014). Evaluating Disease Management Programmes in the Netherlands. Socio-Medical Sciences (SMW).
Cramm, J.M., Tsiachristas, A., Adams, S.A., Walters, B.H., Bal, R.A., Huijsman, R. & Nieboer, A.P. (2014). Evaluatie van disease management programma's in Nederland. Sociaal-Medische Wetenschappen (SMW).
Cramm, J.M. & Nieboer, A.P. (2014). The effects of social and physical functioning and self-management abilities on well-being among patients with cardiovascular diseases, chronic obstructive pulmonary disease, and diabetes.Applied research in quality of life, 9 (1), 113. doi: 10.1007/s11482-013-9216-z.
Tsiachristas, A., Cramm, J.M., Nieboer, A.P. & Rutten - van Molken, M.P.M.H. (2014). Changes in costs and effects after the implementation of disease management programs in the Netherlands: variability and determinants. Cost Effectiveness and Resource Allocation, 12:17. doi: 10.1186/1478-7547-12-17.
Cramm, J.M. & Nieboer, A.P. (2014). A longitudinal study to identify the influence of quality of chronic care delivery on productive interactions between patients and (teams of) healthcare professionals within disease management programmes. BMJ Open, 4:e005914. doi: http://dx.doi.org/doi:10.1136/bmjopen-2014-005914.
Cramm, J.M. & Nieboer, A.P. (2013). High-quality chronic care delivery improves experiences of chronically ill patients receiving care. International Journal for Quality in Health Care, 25 (6), 689-695. doi: http://dx.doi.org/10.1093/intqhc/mzt065.
Cramm, J.M. & Nieboer, A.P. (2013). Short and long term improvements in quality of chronic care delivery predit program sustainability.Social Science & Medicine, 101, 148-154. doi: http://dx.doi.org/10.1016/j.socscimed.2013.11.035.
Cramm, J.M. & Nieboer, A.P. (2013). The relationship between self-management abilities, quality of chronic care delivery, and wellbeing among patients with chronic obstructive pulmonary disease in The Netherlands. International Journal of COPD, 8, 209-214. doi: http://dx.doi.org/10.2147/COPD.S42667.
Cramm, J.M., Tsiachristas, A., Walters, B.H., Adams, S.A., Bal, R.A., Huijsman, R., Rutten - van Molken, M.P.M.H. & Nieboer, A.P. (2013). The management of cardiovascular disease in the Netherlands: analysis of different programmes. International Journal of Integrated Care, 13, 1-16.
Tsiachristas, A., Cramm, J.M., Nieboer, A.P. & Rutten - van Molken, M.P.M.H. (2013). Broader economic evaluation of disease management programs using multi-criteria decision analysis. International Journal of Technology Assessment in Health Care, 29 (3), 301-308. doi: http://dx.doi.org/10.1017/S0266462313000202.
Cramm, J.M. & Nieboer, A.P. (2012). Disease-management partnership functioning, synergy and effectiveness in delivering chronic-illness care. International Journal for Quality in Health Care, 24 (3), 279-285. doi: http://dx.doi.org/10.1093/intqhc/mzs004.
Cramm, J.M. & Nieboer, A.P. (2012). Self-management abilities, physical health and depressive symptoms among patients with cardiovascular diseases, chronic obstructive pulmonary disease, and diabetes. Patient Education and Counseling, 87, 411-415. doi: http://dx.doi.org/10.1016/j.pec.2011.12.006.
Hipple, B.J.A., Adams, S.A., Nieboer, A.P. & Bal, R.A. (2012). Disease management projects and the Chronic Care Model in action: baseline qualitative research. Bmc Health Services Research, 12, 114-132. doi: http://dx.doi.org/10.1186/1472-6963-12-114.
Cramm, J.M. & Nieboer, A.P. (2012). The chronic care model congruency and predictors among patients with cardiovascular diseases and chronic obstructive pulmonary disease in the Netherlands. Bmc Health Services Research, 12 (242). doi: http://dx.doi.org/10.1186/1472-6963-12-242.
Cramm, J.M. & Nieboer, A.P. (2012). Factorial validation of the patient assessment of chronic illness care (PACIC) and PACIC short version (PACIC-S) among cardiovascular disease patients in the Netherlands. Health and Quality of Life Outcomes, 10 (104). doi: http://dx.doi.org/10.1186/1477-7525-10-104.
Cramm, J.M., Rutten - van Molken, M.P.M.H. & Nieboer, A.P. (2012). The potential for integrated care programmes to improve quality of care as assessed by patients with COPD: early results from a real-world implementation study in The Netherlands. International Journal of Integrated Care, 12, 1-7. doi: http://dx.doi.org/10-1-113787/ijic2012-191.
Cramm, J.M. & Nieboer, A.P. (2012). THE CARE SPAN In The Netherlands, Rich Interaction Among Professionals Conducting Disease Management Led To Better Chronic Care. Health Affairs, 31 (11), 2493-2500. doi: http://dx.doi.org/10.1377/hlthaff.2011.1304.
Cramm, J.M. & Nieboer, A.P. (2012). Relational coordination promotes quality of chronic care delivery in Dutch disease-management programs. Health Care Management Review, 37 (4), 301-309. doi: http://dx.doi.org/10.1097/HMR.0b013e3182355ea4.
Cramm, J.M. & Nieboer, A.P. (2012). The role of self-management abilities on physical health and depressive symptoms among patients with cardiovascular diseases, chronic obstructive pulmonary disease, and diabetes. In EUPHA Vol. 22. European Journal of Public Health (pp. 266-267).
Cramm, J.M., Tsiachristas, A., Hipple, B.J.A., Adams, S.A., Bal, R.A., Huijsman, R., Rutten - van Molken, M.P.M.H. & Nieboer, A.P. (2011). Evaluating cardiovascular disease management programmes. Preliminary results. (Extern rapport). Den Haag: ZonMW.
Cramm, J.M., Strating, M.M.H. & Nieboer, A.P. (2011). Development and validation of a short version of the Partnership Self-Assessment Tool (PSAT) among professionals in Dutch Disease-management partnerships. BMC Research Notes, 4 (224). doi: http://dx.doi.org/10.1186/1756-0500-4-224.
Lemmens, K.M.M., Rutten - van Molken, M.P.M.H., Cramm, J.M., Huijsman, R., Bal, R.A. & Nieboer, A.P. (2011). Evaluation of a large scale implementation of disease management programmes in various Dutch regions: a study protocol. Bmc Health Services Research, 11 (6), 1-9.
Tsiachristas, A., Hipple, B.J.A., Lemmens, K.M.M., Nieboer, A.P. & Rutten - van Molken, M.P.M.H. (2011). Towards integrated care for chronic conditions: Dutch policy developments to overcome the (financial) barriers. Health Policy, 101, 122-132. doi: 10.1016/j.healthpol.2010.10.013.
Cramm, J.M., Strating, M.M.H., Tsiachristas, A. & Nieboer, A.P. (2011). Development and validation of a short version of the Assessment of Chronic Illness Care (ACIC) in Dutch Disease Manegement Progams.Health and Quality of Life Outcomes, 9 (49), 1-10. doi: http://dx.doi.org/10.1186/1477-7525-9-49.