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Medical Assistant–Based Care Management for High-Risk Patients in Small Primary Care Practices: A Cluster Randomized Clinical TrialMedical Assistant–Based Care Management in Small Primary Care Practices

Tobias Freund, MD; Frank Peters-Klimm, MD; Cynthia M. Boyd, MD; Cornelia Mahler, MA; Jochen Gensichen, MD; Antje Erler, MD; Martin Beyer, MA; Matthias Gondan, PhD; Justine Rochon, MSc; Ferdinand M. Gerlach, MD; and Joachim Szecsenyi, MD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 2 February 2016.


From University Hospital Heidelberg and University of Heidelberg, Heidelberg, Germany; Johns Hopkins University School of Medicine, Baltimore, Maryland; Friedrich-Schiller University Hospital, Jena, Germany; Goethe University, Frankfurt, Germany; and University of Copenhagen, Copenhagen, Denmark.

Note: This study was awarded the German Primary Care Research Award for 2013 by the German Society of General Practice and Family Medicine (www.online-zfa.de/article/dr-lothar-beyer-preis-und-posterpreise-verliehen/kongresse-congress/y/m/1508).

Acknowledgment: The authors thank all participating primary care practice teams and patients; Markus Qreini for data management; and Annika Baldauf, Marion Kiel, and Martina Bentner for supporting the study as study nurses. The manuscript underwent professional copyediting by Eric Vohr.

Financial Support: By AOK Baden-Württemberg and AOK Bundesverband.

Disclosures: Dr. Freund reports grants from AOK Baden-Württemberg and AOK Bundesverband during the conduct of the study, personal fees from the German Family Physicians' Organization outside the submitted work, and a patent with royalties paid for PraCMan Cockpit software. Dr. Peters-Klimm reports grants from AOK Baden-Württemberg and AOK Bundesverband during the conduct of the study and a patent with royalties paid for PraCMan Cockpit software. Dr. Boyd reports that she receives royalties for coauthoring a chapter on multimorbidity for UpToDate. Dr. Mahler reports grants from AOK Baden-Württemberg and AOK Bundesverband during the conduct of the study and a patent with royalties paid for PraCMan Cockpit software. Dr. Gerlach reports a research grant from the Federal Ministry of Education and Research during the conduct of the study. Dr. Szecsenyi reports grants from AOK Baden-Württemberg and AOK Bundesverband during the conduct of the study and a patent with royalties paid for PraCMan Cockpit software. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/Conflict OfInterestForms.do?msNum=M14-2403.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3141533. Statistical code: Provided in the Supplement. The complete code is available from Dr. Freund (e-mail, tobias.freund@med.uni-heidelberg.de). Data set: Not available.

Requests for Single Reprints: Tobias Freund, MD, Department of General Practice and Health Services Research, University Hospital Heidelberg, Voßstraße 2, 69115 Heidelberg, Germany; e-mail, tobias.freund@med.uni-heidelberg.de.

Current Author Addresses: Drs. Freund, Peters-Klimm, Mahler, and Szecsenyi: Department of General Practice and Health Services Research, University Hospital Heidelberg, Voßstraße 2, 69115 Heidelberg, Germany.

Dr. Boyd: Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Building, Center Tower, 5200 Eastern Avenue, Baltimore, MD 21224.

Dr. Gensichen: Institute of General Practice, Friedrich-Schiller University Hospital Jena, Bachstraße 18, 07743 Jena, Germany.

Drs. Erler and Gerlach and Mr. Beyer: Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.

Dr. Gondan: Department of Psychology, University of Copenhagen, Øster Farimagsgade 2A, 1353 Copenhagen, Denmark.

Ms. Rochon: Institute of Biometry and Medical Informatics, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany.

Author Contributions: Conception and design: T. Freund, F. Peters-Klimm, C. Mahler, J. Gensichen, A. Erler, M. Beyer, F.M. Gerlach, J. Szecsenyi.

Analysis and interpretation of the data: T. Freund, F. Peters-Klimm, C.M. Boyd, C. Mahler, J. Gensichen, A. Erler, M. Gondan, J. Rochon, F.M. Gerlach, J. Szecsenyi.

Drafting of the article: T. Freund, A. Erler, M. Gondan, J.Szecsenyi.

Critical revision of the article for important intellectual content: F. Peters-Klimm, C.M. Boyd, C. Mahler, J. Gensichen, A. Erler, M. Beyer, F.M. Gerlach, J. Szecsenyi.

Final approval of the article: T. Freund, F. Peters-Klimm, C.M. Boyd, C. Mahler, J. Gensichen, A. Erler, M. Beyer, M. Gondan, J. Rochon, F.M. Gerlach, J. Szecsenyi.

Provision of study materials or patients: F. Peters-Klimm, A. Erler, F.M. Gerlach.

Statistical expertise: M. Gondan, J. Rochon.

Obtaining of funding: T. Freund, F. Peters-Klimm, J.Szecsenyi.


Ann Intern Med. 2016;164(5):323-330. doi:10.7326/M14-2403
© 2016 American College of Physicians
Text Size: A A A

Background: Patients with multiple chronic conditions are at high risk for potentially avoidable hospitalizations, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices.

Objective: To determine whether protocol-based care management delivered by medical assistants improves care in patients at high risk for future hospitalization in primary care.

Design: Two-year cluster randomized clinical trial. (Current Controlled Trials: ISRCTN56104508)

Setting: 115 primary care practices in Germany.

Patients: 2076 patients with type 2 diabetes, chronic obstructive pulmonary disease, or chronic heart failure and a likelihood of hospitalization in the upper quartile of the population, as predicted by an analysis of insurance data.

Intervention: Protocol-based care management, including structured assessment, action planning, and monitoring delivered by medical assistants, compared with usual care.

Measurements: All-cause hospitalizations at 12 months (primary outcome) and quality-of-life scores (12-Item Short Form Health Survey [SF-12] and EuroQol instrument [EQ-5D]).

Results: Included patients had an average of 4 co-occurring chronic conditions. All-cause hospitalizations did not differ between groups at 12 months (risk ratio [RR], 1.01 [95% CI, 0.87 to 1.18]) and 24 months (RR, 0.98 [CI, 0.85 to 1.12]). Quality of life (differences, 1.16 [CI, 0.24 to 2.08] on SF-12 physical component and 1.68 [CI, 0.60 to 2.77] on SF-12 mental component) and general health (difference on EQ-5D, 0.03 [CI, 0.00 to 0.05]) improved significantly at 24 months. Intervention costs totaled $10 per patient per month.

Limitation: Small number of primary care practices and low intensity of intervention.

Conclusion: This low-intensity intervention did not reduce all-cause hospitalizations but showed positive effects on quality of life at reasonable costs in high-risk multimorbid patients.

Primary Funding Source: AOK Baden-Württemberg and AOK Bundesverband.

Figures

Grahic Jump Location
Appendix Figure.

Study flow diagram.

PCP = primary care physician.

Grahic Jump Location

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