Chronic Diseases Clinical Trial
Official title:
Pragmatic Evaluation of Case Management and Self-management Support for Vulnerable People With Chronic Diseases in Primary Care
The purpose of this study is to implement a pragmatic intervention in four (4) family medicine groups(FMGs) in the region of Saguenay-Lac-Saint-Jean (Quebec, Canada)for patients with chronic diseases.
Chronic diseases represent a major health burden worldwide. Some people with chronic
diseases require a higher level of care due to personal characteristics that increase their
vulnerability. For these patients, nurse effective case management in primary care are
associated with positive outcomes. Moreover, self-management programs, such as the standford
program developed by the School of Medicine at the University of Standford in California
(USA), are also recognized for their benefits on patients with chronic diseases.
The aim of our project is to implement, within four (4) FMGs of the region of
Saguenay-Lac-Saint-Jean , a practical intervention involving case management by a nurse to
promote interdisciplinary person-centered monitoring and self-management support for highly
vulnerable individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory
diseases, musculoskeletal diseases and/or chronic pain).
The objectives of our study : 1) To analyze the implementation of the intervention in the
participating FMGs in order to determine how the various contexts have influenced the
implementation and the observed effects; 2) To evaluate the proximal and intermediate
effects of the intervention on patients; 3) To conduct an economic analysis of the
effectiveness and cost-benefit of the intervention.
The analysis of the implementation will be conducted using realistic evaluation approaches
and participatory practice within four categories of key players (FMG stakeholders,
FMG/health center managers, patients and their families, health center partners or
communities). The data will be obtained through individual or group interviews, literature
reviews and documentation from the intervention undertaken. The evaluation of the effects in
patients will be based on a pragmatic randomized experimental design before and after (six
months) with delayed intervention in the control group. Economic analysis will include a
cost-effectiveness analysis and a cost-benefit analysis.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Supportive Care
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