Evaluation of Estonia’s enhanced care management program: protocol for a cluster randomized trial
DOI:
https://doi.org/10.18203/2349-3259.ijct20240041Keywords:
NCDs, Health systems, Aging, Chronic illness, Primary health care, Quality of care, Randomized control trialAbstract
Background: Estonia’s aging population faces an increasing burden of non-communicable diseases (NCDs) and a growing population suffers with multiple chronic conditions. These changes have reduced well-being and quality of life for many older Estonians, while increasing the use of high cost specialist and emergency care. In response, the Estonia Health Insurance Fund (EHIF) is working to support primary care physicians to improve care for complex patients with multiple chronic conditions. A new EHIF program, Enhanced Care Management (ECM), trains family physicians to identify complex patients, co-develop proactive care plans with them, and conduct more active outreach and management of these patients.
Methods: In this protocol we describe a randomized controlled trial, developed in partnership with EHIF, to evaluate the impact of ECM training for physicians. The RCT enrolled a randomly selected 97 family physicians out of the 786 family physicians practicing in Estonia. Among those physicians’ 6,739 ECM-eligible patients, 2,389 patients were randomly selected for enrolment into the ECM program.
Results: Using administrative records, we evaluated the effects of ECM enrolment on: (1) health care utilization; (2) provider management of tracer conditions; and (3) markers of quality of care such as hospital admission for primary health care-sensitive conditions.
Conclusions: This protocol presents a pre-specified analysis plan for this evaluation of Estonia’s ECM program.
Trial registration: First registered with the American Economics Association, AEARCTR-0003661. Registered May 1, 2019. Retrospective secondary registration with www.clinicaltrials.gov P169891. Registered April 26, 2023.
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References
World Health Organization. Noncommunicable diseases: Progress monitor 2020. Available at: https://www.who.int/publications/i/item/9789240000490. Accessed on 1 June 2023
King DE, Xiang J, Pilkerton CS. Multimorbidity trends in United States adults, 1988-2014. J Am Board Fam Med. 2018;31(4):503-13.
Rijken M, Nienke B, Pauline B, François GS, Jan MDM, Peter PG. Chronic disease management programmes: An adequate response to patients’ needs? Heal Expect. 2014;17(5):608-21.
Van den Akker M, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA. Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol. 1998;51:367-75.
Walker AE. Multiple chronic diseases and quality of life: Patterns emerging from a large national sample, Australia. Chronic Illn. 2007;3:202-18.
Gijsen R, Hoeymans N, Schellevis FG, Ruwaard D, Satariano WA, Van Den Bos GA. Causes and consequences of comorbidity: A review. J Clin Epidemiol. 2001;54(7):661-74.
Avoiding unplanned admissions: Proactive case finding and patient review for vulnerable people. Guidance and audit requirements. A programme of action for general practice and Clinical commissioning groups. NHS England Gateway. 2014. Available at: https://www.mysurgerywebsite. co.uk/website/IGP367/files/Avoiding_unplanned_admissions-guidance_and_audit_requirements_for_2014.15_Version-June14.pdf. Accessed on 12 October, 2023.
Leeds: NHS England. 2015.
David G, Gunnarsson C, Saynisch PA, Ravi C, Somesh N. Do patient-centered medical homes reduce emergency department visits? Heal Services Res. 2015;50(2):418-39.
Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multi-morbidity in primary care and community settings. Cochrane Database Systematic Rev. 2021;1(1):CD006560.
Rosenthal TC. The medical home: Growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008;21(5):427-40.
Finkelstein A, Zhou A, Taubman S, Doyle J. Health care hot spotting-A randomized controlled trial. New Engl. J Med. 2020;382(2):152-62.
World Bank. The state of health care integration in Estonia. 2015.
The World Bank, Estonia population. 2019. Available at: https://data.worldbank.org/country/estonia. Accessed on 12 October, 2023.
Atun R, Gurol-Urganci I, Hone T, Pell L, Stokes J, Habicht T et al. Shifting chronic disease management from hospitals to primary care in Estonian health system: Analysis of national panel data. J Global Healt. 2016;6(2):020701.
Habicht J, Van Ginneken E. Estonia’s health system in 2010. Meas Quality long-term care. 2010;16:29.
Koppel A, Kahur K, Habicht T, Saar P, Jarno H. Ewout Van Ginneken et al. Estonia: Health system review. Health Systems Transition. 2008;1-230(10):1-230.
Peikes D, Stacy D, Arkadipta G, Erin FT, Kaylyn S, Ann SO'M et al. The comprehensive primary care initiative: Effects on spending, quality, patients, and physicians. Health Aff. 2018;37(6):890-99.
Kurowski C, Chandra A, Finkel E, Marvin P, Eesti H. The state of health care integration in Estonia: Summary report. World Bank Group. Publisher: Estonian Health Insurance Fund. 2015.
Blackwell M, Iacus S, King G, Giuseppe P. CEM: Coarsened exact matching in Stata. The Stata J. 2009;9(C):524-46.
Croke K, Daniels B, Rogger D. Improving incentives for fairness in QBS: A “need-adjusted” approach to coverage. Report. 2019;1-22.
OECD. Health at a Glance 2021. 2021. Available at: https://www.oecd.org/health/health-at-a-glance/. Accessed on 23 October, 2023.
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