Evaluation of Estonia’s enhanced care management program: protocol for a cluster randomized trial


  • Benjamin Daniels McCourt School of Public Policy, Georgetown University, Washington DC, USA
  • Daniel Rogger Development Impact Evaluation, World Bank, Washington DC, USA
  • Meyhar Mohammed Development Impact Evaluation, World Bank, Washington DC, USA
  • Katre Vaarsi Development Impact Evaluation, World Bank, Washington DC, USA
  • Kevin Croke Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston MA, USA




NCDs, Health systems, Aging, Chronic illness, Primary health care, Quality of care, Randomized control trial


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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