Primary care practice based care management for chronically ill patients

Not Applicable

Completed

• Conditions: Chronic disease management; Type 2 diabetes mellitus; Chronic obstructive pulmonary disease; Chronic heart failure and comorbid conditions; Not Applicable

• Registration Number: ISRCTN56104508
• Lead Sponsor: niversity Hospital Heidelberg (Germany)

Brief Summary

Not available

Detailed Description

Not available

Study Timeline

• Study Start: 2010-11-24
• Last Update Posted: 17 October 2016

Recruitment & Eligibility

• Status: Completed
• Sex: All
• Target Recruitment: 2700

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

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

Study & Design

• Study Type: Interventional
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
umber of all-cause hospitalisations within 12 months of intervention/control

Secondary Outcome Measures

Name	Time	Method
1. Health related quality of life (SF-12, EQ5D)<br>2. Medication adherence<br>3. Self-management<br>4. Patient reported delivery of chronic care elements (PACIC)<br>5. Health care costs<br>6. Contacts with specialists/generalists and supportive services<br>7. Mortality<br>8. Clinical status<br>9. Depression <br>All outcomes will be assessed at 12 and 24 months.