Figure 1
Schematic representation of the Person-Centred and Integrated Care (PC-IC) approach* [2] for the management of patients with chronic diseases and multimorbidity in primary care.
* In Step 1 and Step 2 of the PC-IC approach, the Positive Health Tool was implemented. It encompasses six domains: bodily functions, mental and emotional well-being, meaningfulness, quality of life, social well-being/participation, and daily functioning. (4) In Step 1, the patient prepares for the consultation with the healthcare professional by answering questions, preferably digitally. The answers to the questions result in a visual aid (‘Spider Web’), for the discussion between patient and healthcare professional (Step 2). In consultation with the healthcare professional, the patient decides which domain has priority and which personal (health) goals he wants to achieve (Step 3). The healthcare professional discusses with the patient which treatments and support are most suitable for the patient (Step 4) and records the health goals and the chosen treatments (interventions) in a digitalized individual care plan (Step 5) that can be shared with other care providers involved. In Step 6, the selected treatments and other support takes place, after or during which one or more (interim) evaluation visits can be planned, depending on the patient’s needs (Step 7). After a predefined period, for example a year, the patient’s health status is reassessed and the cyclic clinical process repeated.
Table 1
Longlist of suitable questionnaires; questionnaires written in italic typeface were chosen in a consensus meeting of the project team to be used in the feasibility study.
| POPULATION HEALTH | |||||
|---|---|---|---|---|---|
| OUTCOME | QUESTIONNAIRE | AUTHORS/SOURCE | DUTCH VALIDATED VERSION | NUMBER OF QUESTIONS | SCORING RANGE* |
| Quality of Life | Satisfaction with Life Scale (SWLS) | Diener, 1985 [8]. | Yes | 5 | 5–35 |
| Life Satisfaction Questionnaire (LSQ) | Fugl-Meyer, 1991 [9]. | Yes | 9 | 1–6 | |
| Health state | EQ-5D-5L | Herdman, 2011 [10]. | Yes | 6 | –0.446–1 |
| SF12 | Ware, 1996 [11]. | Yes | 12 | 0–100 | |
| Functioning and participation | ICF Primary Care instrument | Postma, 2018 [12]. | Yes | 73 | 1–5# |
| Self-management | Patient Activation Measure (PAM) | Hibbard, 2004 [13]. | Yes | 13 | 0–100 |
| Health related quality of life | PROMIS global 10 | Hays, 2009 [14]. | Yes | 10 | T-score |
| Well-being | Well-being of Older People (WOOP) | Hackert, 2021 [15]. | Yes | 9 | 9–45 |
| Well-being | ICE-CAP-O | Makai, 2013 [16]. | Yes | 5 | 0–1.00 |
| PATIENT EXPERIENCE | |||||
| OUTCOME | QUESTIONNAIRE | AUTHORS/SOURCE | DUTCH VERSION | NUMBER OF QUESTIONS | SCORING RANGE* |
| Chronic care | Patient Assessment of Care for Chronic Conditions (PACIC) | Glasgow, 2005 [17]. | Yes | 20 | 1–5 |
| Quality of primary care | Consumer Quality Index (CQ-index) Daytime General Practice Care | Meuwissen, 2009 [18]. | Yes | 53 | 0–10 |
| Patient experience of chronic care in primary care | PREM Chronic care | Hendriks, 2016 [19]. | Yes | 25 | Net promotor score |
| Person centred coordinated care experiences | Person Centred Coordinated Care Experiences Questionnaire (P3CEQ) | Lloyd, 2019 [20]. | Yes | 11 | 0–30 |
| Person centred care experience | Person Centred Primary Care Measure (PCPCM) | Etz, 2019 [21]. | No | 11 | 8–44 |
| Continuity of care | Nijmegen Continuity Questionnaire (NCQ) | Uijen, 2011 [22]. | Yes | 30 | 1–5 |
[i] * Higher score is better. # Higher score is worse.
Figure 2
Flowchart of inclusion of patients and healthcare professionals.
Table 2
Characteristics of the patients and healthcare professionals participating in the feasibility study.
| PATIENTS | NUMBER (%) (n = 96) |
|---|---|
| Sex, male | 36 (38%) |
| Age, ≥65 years | 48 (50%) |
| Paid work, yes | 37 (39%) |
| Educational level1 | |
| Low | 36 (38%) |
| Middle | 28 (30%) |
| High | 30 (31%) |
| Limited literacy2 | 21 (22%) |
| Lifestyle | |
| Alcohol consumption, average of ≥1 glass/day | 28 (29%) |
| Active smoking, yes | 21 (22%) |
| Exercise, ≥5 days per week3 | 47 (49%) |
| Polypharmacy, chronic use of ≥5 different medications4 | 47 (49%) |
| ≥3 chronic diseases, yes | 50 (52%) |
| sDMP inclusion | |
| COPD/asthma, yes | 32 (33%) |
| CVRM, yes | 87 (91%) |
| Diabetes, yes | 43 (45%) |
| Included in 2 sDMPs5 | 24 (25%) |
| HEALTHCARE PROFESSIONALS | NUMBER (%) (n = 26) |
| Sex, male | 5 (19%) |
| Practice nurses | 13 (50%) |
| General practitioners | 13 (50%) |
| 5 or more years relevant working experience | 18 (69%) |
| Healthcare professionals | Number (%)(n = 26) |
| Type of practice | |
| Solo practice | 8 (31%) |
| Group practice | 12 (46%) |
| Practice integrated in multidisciplinary healthcare center | 6 (23%) |
[i] 1 Educational level was determined based on the highest completed education, creating 3 groups:
High: higher vocational or university education,
Middle: higher secondary general education or post-secondary vocational education,
Low: all other types of education.
2 Patients who reported to ever have experienced problems with reading medical flyers or information.
3 Based on the Dutch exercise guideline [29] that states to exercise at least 5 days a week for at least 30 minutes per session.
4 Polypharmacy is defined as the chronic use of 5 or more different medications [3031]. We excluded dermatological medications, ferrous fumarate, artificial tears, vitamins, and fibres. Other eye drops were included if they were chronically used. Medications were included in chronic use if they were prescribed for ≥90 days. Combination preparations were counted as 2 separate medications.
5 The combination Diabetes sDMP and CVD/CVRM sDMP was not included as patients with both DM2 and CVD or elevated cardiovascular risk are only treated in the sDMP for DM2.
Table 3
Scores on the selected questionnaires for the outcomes ‘patient experience’ and ‘population health’ in 96 patients with one or more chronic conditions. Questionnaires marked italic were selected for the forthcoming evaluation study.
| QUESTIONNAIRE | COMPLETED QUESTIONNAIRE AT BASELINE (n) | COMPLETED QUESTIONNAIRE AT 6 MONTHS FOLLOW UP + (n) | MEDIAN (IQR) SCORE AT BASELINE | MEAN (SD) AT BASELINE | MEAN CHANGE | p-VALUE | MCID† | n (%) NEGATIVE MCID | n (%) NO CHANGE | n (%) POSITIVE MCID | n (%) DIFFICULTY WITH QUESTIONS (n = 86) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| EQ-5D-5L index | 96 | 79 | 0.85 (0.1) | 0.83 (0.19) | –0.01 | 0.470* | 0.10 | 13 (16.5) | 58 (73.4) | 8 (10.1) | 8 (9.3) |
| EQ-5D-5L visual analogue scale (VAS) | 96 | 79 | 80 (20) | 77.49 (16.02) | 1.87 | 0.09* | 8.01 | 11 (13.9) | 49 (62.0) | 19 (24.1) | 8 (9.3) |
| Life Satisfaction Questionnaire (LSQ) | 91 | 79 | 5 (0.7) | 4.97 (0.59) | –0.02 | 0.567* | 0.30 | 17 (22.7) | 43 (57.3) | 15 (20.0) | 10 (11.6) |
| Person-Centred Coordinated Care Experience Questionnaire (P3CEQ) | 96 | 79 | 14.0 (9.8) | 12.65 (6.19) | –0.23 | 0.924* | 3.10 | 20 (25.3) | 40 (50.6) | 19 (24.1) | 18 (20.9) |
| Patient Activation Measure (PAM) | 88 | 72 | 62.5 (19.8) | 64.63 (14.62) | 0.62 | 0.394* | 7.31 | 11 (16.7) | 39 (59.1) | 16 (24.2) | 15 (17.4) |
| PROMIS–general physical health (GPH) | 96 | 79 | 45.7 (11.3) | 45.82 (7.90) | 0.96 | 0.071# | 3.95 | 10 (12.7) | 51 (64.6) | 18 (22.8) | 6 (7.0) |
| PROMIS–general mental health (GMH) | 96 | 79 | 45.3 (8.3) | 46.74 (6.64) | –0.50 | 0.843* | 3.32 | 17 (21.5) | 49 (62.0) | 13 (16.5) | 6 (7.0) |
| Satisfaction with Life Scale (SWLS) | 96 | 79 | 29 (9.8) | 26.80 (6.82) | –0.09 | 0.997* | 3.41 | 14 (17.7) | 51 (64.6) | 14 (17.7) | 17 (19.8) |
| Well-being of Older People (WOOP) | 96 | 79 | 37.1 (5.1) | 37.07 (4.49) | –0.27 | 0.290* | 2.25 | 18 (22.8) | 50 (63.3) | 11 (13.9) | 5 (5.8) |
[i] +Statistical tests were only performed on paired values of 79 participants who completed all questionnaires. Baseline characteristics were similar to the group of 96 patients. *Wilcoxon test; † MCID defined as 0.5 × SD of the baseline questionnaire score; # Paired t-test. MCID = minimal clinically important difference; PROMIS = patient reported outcomes measurement information system; SD = standard deviation.
Table 4
Different scenarios for the composite primary outcome for the evaluation study.
| QUESTIONNAIRE: | n (%) |
|---|---|
| PROMIS GPH; MCID improved | 18 (22.8) |
| PROMIS GMH; MCID improved | 13 (16.5) |
| P3CEQ; MCID improved | 19 (24.1) |
| Scenarios for combining the three questionnaires* to define the composite primary outcome: | |
| MCID improved of at least one (decrease allowed) | 37 (46.8) |
| MCID improved of at least one (no decrease allowed) | 24 (30.4) |
| MCID improved of at least two (decrease allowed) | 9 (11.4) |
| MCID improved of at least two (no decrease allowed) | 8 (10.1) |
| MCID improved of all three questionnaires | 4 (5.1) |
[i] * PROMIS GPH & GMH & P3CEQ; GPH = general physical health; GMH = mental health; MCID = minimal clinically important difference; P3CEQ = Person Centred Coordinated Care Experiences Questionnaire; PROMIS = patient reported outcomes measurement information system.