Participatory Patient Care Planning in Primary Care

NCT02992431 | Unknown

• 1 other identifier: 749-1-2017
• Study Type: interventional
• Target: 600
• Locations: 1 country
• Sites: 1

Brief Summary

In the aging population, the prevalence of chronic diseases and multimorbidity has become common. Therefore, the planning and coordination of care have become more important. However, it is not known what kind of treatment plan should be and what kind of patients would benefit most of it. This research focuses on the participatory patient care planning in primary health care. In general, the participatory patient care planning (PPCP) aims to engage patients in self-care, to improve the collaboration between patients and professionals and to improve the use of resources. The present study investigates the feasibility and effectiveness of the PPCP. The specific research questions of the present study are: Does the PPCP have an impact on the patient's quality of life? Does the PPCP improve the quality of care in management of chronic diseases? Does the PPCP improve patient's commitment with self-care? Does the PPCP impact on the use of health care services? The data consists of people aged at least 18 years living in the municipality of Siilinjärvi with diabetes, coronary heart disease or hypertension and who are recorded in in Siilinjärvi Health Care Center electronic patient record. The participating patients are recruited from those who contacts SiiIinjärvi Health Care Center in order to have a follow-up visit because of the treatment of their disease. This study aims to recruit 700 patients. The participants are allocated into the intervention group and into the control group receiving usual care. Intervention consists of the PPCP. This includes the patient activation questionnaire form, a visit to the nurse who conducts the measurements (blood pressure, waist measurement, weight and length) and a visit to the general practitioner who discusses and agrees with the patient about the treatment goals and follow-up resulting in the written PPCP. The main out-come measures are the quality of health related life measured with the 15D; the level of patient's activity in self-care with the Patient Activation Measurement (PAM); life satisfaction, self-rated health, a reduction in productivity with the Work Productivity and Activity Impairment Questionnaire (WPAI: GH), and the disease specific measures (blood pressure, HbA1C, LDL-cholesterol, body mass index and waist measurement). In addition, pain intensity and interference (NRS 0-10), mood (BDI-21), the number of visits and phone calls and referrals are measured.

Conditions

Hypertension; Ischemic Heart Disease; Diabetes Mellitus

Keywords

patient care planning; primary health care; comorbidity

Outcome Measures

Primary Outcomes (1)

• 15D

  Health related quality of life

  one year

Secondary Outcomes (9)

• WPAI

  one year

• PAM

  one year

• HbA1C

  one year

• LDL

  one year

• blood pressure

  one year

Study Arms (2)

Usual care

ACTIVE COMPARATOR

Usual care including standard disease specific follow-up with visit to general practitioner.

Other: Usual care

Participatory patient care planning

EXPERIMENTAL

Intervention includes the patient activation questionnaire form, a visit to the nurse who conducts the measurements (blood pressure, waist measurement, weight and length) and a visit to the general practitioner who discusses and agrees with the patient about the treatment goals and follow-up resulting in the written PPCP.

Behavioral: Participatory patient care planning

Interventions

Participatory patient care planning BEHAVIORAL

Intervention includes the patient activation questionnaire form, a visit to the nurse who conducts the measurements (blood pressure, waist measurement, weight and length) and a visit to the general practitioner who discusses and agrees with the patient about the treatment goals and follow-up resulting in the written PPCP.

Participatory patient care planning

Usual care OTHER

Usual care including standard disease specific follow-up with visit to general practitioner.

Usual care

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Patients with hypertension, ischemic hearth disease or diabetes living in the municipality of Siilinjärvi

You may not qualify if:

• Permanent bed patient, terminal phase of any serious condition, severe decline in cognition

Sponsors & Collaborators

• Kuopio University Hospital: lead
• Siilinjärvi Health Center: collaborator
• University of Eastern Finland: collaborator

Study Sites (1)

Siilinjärvi Health Center

Siilinjärvi, 71800, Finland

Location

Related Publications (4)

• Tusa N, Mikkonen U, Kautiainen H, Mantyselka P. Participatory care plan for primary care patients with long-term diseases: results after a 36-month follow-up of a randomized controlled trial. BMC Health Serv Res. 2025 Apr 12;25(1):536. doi: 10.1186/s12913-025-12660-6.

  PMID: 40217248 DERIVED

• Tusa N, Kautiainen H, Elfving P, Sinikallio S, Mantyselka P. Depressive symptoms decrease health-related quality of life of patients with coronary artery disease and diabetes: a 12-month follow up study in primary care. Scand J Prim Health Care. 2023 Sep;41(3):276-286. doi: 10.1080/02813432.2023.2233995. Epub 2023 Jul 16.

  PMID: 37455531 DERIVED

• Tusa N, Kautiainen H, Elfving P, Sinikallio S, Mantyselka P. Randomized controlled study of the impact of a participatory patient care plan among primary care patients with common chronic diseases: a one-year follow-up study. BMC Health Serv Res. 2021 Jul 20;21(1):715. doi: 10.1186/s12913-021-06716-6.

  PMID: 34284783 DERIVED

• Tusa N, Kautiainen H, Elfving P, Sinikallio S, Mantyselka P. Relationship between patient activation measurement and self-rated health in patients with chronic diseases. BMC Fam Pract. 2020 Nov 4;21(1):225. doi: 10.1186/s12875-020-01301-y.

  PMID: 33148185 DERIVED

MeSH Terms

Conditions

Hypertension; Myocardial Ischemia; Diabetes Mellitus

Condition Hierarchy (Ancestors)

Vascular Diseases; Cardiovascular Diseases; Heart Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases; Endocrine System Diseases

Study Officials

• Pekka T Mäntyselkä, Professor

  University of Eastern Finland

  STUDY CHAIR

• Nina M Tusa, MD

  University of Eastern Finland

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Professor

Study Record Dates

• First Submitted: December 12, 2016
• First Posted: December 14, 2016
• Study Start: January 1, 2017
• Primary Completion: December 1, 2023
• Study Completion: December 1, 2023
• Last Updated: March 31, 2022

Record last verified: 2022-03

Data Sharing

• IPD Sharing: Will not share

Locations

FI (1)