Chronic disease management: Discussing the perspectives of general practitioners in Italy

Abstract

The aim of this paper is to provide an overview of general practitioners’ perspectives across key criteria for effective chronic disease management. The study setting is the Tuscany Region in Italy that implemented the Chronic Care Model in 2010 with multidisciplinary team to assist chronic patients. We used the results of a web-based survey of general practitioners (N = 1136) conducted in 2015 to compare the experiences and satisfaction of general practitioners involved (group 1) and not involved (group 2) in the Chronic Care Model. The analysis included all general practitioners, and compared the two groups’ perspectives of the different core aspects of Chronic Care Model through conducting an ANOVA analysis and Bonferroni test. General practitioners involved in the Chronic Care Model are found to be more favourably disposed toward measurement and benchmarking, and more satisfied in terms of decision support system. Conversely, no significant differences were found in terms of collaboration with specialists, which remains weak and in terms of community collaboration and involvement. This study provides a detailed investigation of the implementation of Disease Management Programs, by considering the professional point of view.

Keywords

chronic Care Model general practitioner primary care satisfaction

Background

At an international level, many healthcare policy makers have sought strategies to effectively and efficiently take care of chronic patients, which typically include the implementation of Disease Management Programs (DMPs). The Chronic Care Model (CCM) and its adaptations are an example of a proactive disease management approach aimed at efficiently and cost-effectively managing the non-acute chronic conditions of a disease. The CCM is designed to help practices improve patient health outcomes by transforming daily care for patients with chronic illnesses from acute and reactive to proactive, planned and population-based, through a combination of effective team care and planned interactions, self-management support, integrated decision support and patient registries.¹ It has six core elements, as shown in Table 1.

Table 1.

Six different elements of the CCM adapted from Grover and Joshi.²

Element	Description
Health organization	Entity desiring to implement CCM is composed of staff, leaders, operations, values and goals of the organization and may vary from a small family practice to a multisite integrated health system.
Clinical information systems (CIS)	Needs to have readily accessible disease-specific database of individual patients, and this database should alert the provider to needed tests and provide tracking. The system should facilitate and promote exchange of information between providers and patients.
Decision support	Defined as evidence-based guidelines consistent with scientific evidence and patient preference. These guidelines should be embedded into daily practice and should be shared with patients to encourage participation.
Delivery system design	Involves how care delivery services are organized, staffed and delivered. This element is typically where care innovations are implemented and represents an important opportunity to improve quality of care and health outcomes of patients.
Self-management support	Emphasizes patient’s role in managing health. Established self-management techniques such as mutual goal setting and action planning have focused on various methods of teaching such as group classes, skill development, and various lifestyle behaviors.
Community including organizations and resources for patients	Involves linking and using community resources that support healthcare effort by clinicians. The use of church-based support groups, local community health programs, clinic-based support groups and internet are acceptable community interventions.

CCM: Chronic Care Model.

The application of the CCM to multiple illnesses is widespread, and studies have provided a rigorous evaluation of its individual components, underlining the positive effects on patient outcomes and processes of care.³ Published evidence suggests that if practices are redesigned in accordance with the CCM, the quality of care and the outcomes for patients with various chronic illnesses are generally improved.^4–6 The opinions of key stakeholders concerning the readiness of the healthcare system to deliver effective Chronic Disease Management (CDM) are vital when assessing on-going reforms within a complex system such as healthcare.⁷ The quality improvement the CCM provides to chronic patients is a subject of debate, and many studies have revealed positive impacts on patients and diseases,⁸ but few focus on the experience and satisfaction of professionals regarding the implementation of the model. Many authors stress the importance of drivers that facilitate the implementation of primary care strategies and models.^9,10 The quality of the relationships among key actors, commitment and trust in the new model and tools is identified as possible necessary factors for a successful implementation of reform. Fernandez et al.¹¹ examined physicians' perceptions of how DMPs affect their practices, their relationships with their patients, and overall patient care. In this study, general practitioners (GPs) provide generally positive perceptions of the effects of voluntary, primary care-inclusive and DMPs on their patients and on levels of satisfaction in their own practices. The majority of primary care physicians with experience of DMPs reported that the programs increased their practice satisfaction (48%) and did not change the quality of their relationships with patients (78%).¹¹

Two recent reviews^5,8 have provided evidence of the effectiveness of elements included in a CCM in improving both healthcare practices and health outcomes within primary healthcare settings. They both identify primary care physicians’ perspectives on disease management as a key variable for the effective implementation of the programs.

Davy et al.⁶ found that drivers such as supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring leader support may contribute to improvements in healthcare practice or health outcomes. The authors reported that the majority of the papers identified an association between the implementation of CCM elements and improvements with healthcare practice or health outcomes. In particular, reflective practice is a key component for developing clinical knowledge and skills and can lead to significant improvements in healthcare, by assisting to bridge the gap between theory and current practice. A reflective practice involves analysing one’s own experiences and modifying behaviour to improve the way in which healthcare is provided.

Another recent literature review on the implementation of the CCM reveals possible facilitating factors and barriers for the implementation of the model.⁸ The authors identified the following issues as drivers for the implementation of the CCM: (i) Networks and communication, i.e. strong networks and increased communication between healthcare providers and organizations; (ii) an organizational culture that promotes multidisciplinary practices; (iii) the implementation climate, such as provider dissatisfaction with the current system; (iv) structural characteristics, with a focus on specialists and non-physician staff such as nurse practitioners, whose responsibilities and scope of practice are broadened; (v) engaging leadership; (vi) knowledge and beliefs about the intervention, such as clinical assessment tool accepted and endorsed or staff morale and burnout reduction associated with reports of improved care outcomes. Barriers to implementation are related to⁸: (i) execution, such as additional responsibilities and sustainability; (ii) structural characteristics, such as size, whether a team-based approach is taken and flexibility in reorganizing care; (iii) readiness for implementation, such as a lack of interest or commitment from the leadership; (iv) engagement, i.e. a lack of leadership accountability or senior management support; (v) knowledge and beliefs, such as concerns about losing patient control to the education program, the time needed for providers to develop trust in the program and the requirement of more information about structured assessment.

The opinions of key stakeholders concerning the readiness of the healthcare system to deliver an effective CDM are vital when assessing on-going reforms within a complex system such as healthcare.⁸ GPs in particular are central to the reorganization model and are responsible for the continuity and coordination of care. In CDM implementation, bridging the knowledge-to-practice gap is a major concern. As Carlfjord et al.¹² underline, implementing new methods, such as guidelines or tools into routine care, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. Many studies underline the importance of behavioural changes in designing implementation strategies for new methods into healthcare.¹³ However, assessments of the possible influence of DMPs from the perspective of professionals are still lacking. To the best of our knowledge, no previous studies compare GP perspectives or the experiences of GPs involved and those not involved in CCMs. Discussing positive (and eventually negative) opinions about change may helped in forming a receptive regional context, one of the factors that determine innovativeness in primary care organizations,¹⁴ while discussing the negative opinions in the implementation of a change may help to identify gaps in order to rethink the program. In this study, the characteristics of the CCM are investigated, by examining the experiences and satisfaction of GPs who joined the disease program compared with those who are not involved in CCM. The framework of the comparison of the perceptions of GPs includes the six core elements of the CCM, as shown in Table 1.

Study setting

The study setting is the Tuscany Region in Italy. The importance of a single case study in theoretical hypothesis testing¹⁵ has been stressed, despite the inevitable external validity problems involved. In this study, the perspective of GPs on the CCM adopted in the limited and specific context of Tuscany is investigated, which provides a valuable opportunity to analyse the CCM as an implicit comparative study among similar contexts. In Italy, GPs are the first contact for the most common health problems and they act as gatekeepers for drug prescriptions and for access to secondary and hospital care. They help to deliver various primary care services, such as health promotion and preventive care activities, diagnosis, treatment, and the follow-up of non-complex, acute and chronic conditions. Thus, they play a key role in coordinating services for patients with chronic diseases. Italian GPs are not directly employed by the national healthcare service but work as independent contractors, and are paid through a combination of a capitation formula, a fee for services and incentives. Tuscany has approximately 3,700,000 residents (around 6% of the total population of Italy). In 2015, Tuscany had 12 local health authorities and 4 teaching hospitals, and about 2700 GPs. The Tuscany Region implemented the CCM in 2010, and teams composed of GPs and nurses, physiotherapists, dieticians, and medical specialists were created to assist chronic patients, with specific tasks for each professional group.¹⁶ The teams identified diagnostic and therapeutic pathways using international guidelines, and explicit recommendations that were compatible with the resources available were provided to the GPs. Each team comprised 5–15 GPs, and at least one nurse per 10,000 patients. Nurses were responsible for contacting patients for routine services, scheduling specialist visits, managing individual or group patient counselling, providing self-management support, and recording patient basic data (such as weight, waist circumference, blood pressure, and blood glucose).¹⁷ The Tuscan CCM program has been implemented for patients with diabetes, heart failure, hypertension, ictus, and COPD. The GPs voluntarily joined the new model of care, and an incentive scheme was set up for GPs enrolled in the CCM. In 2015, at regional level, the GPs that joined voluntary the CCM were 1457 (55% of the total GPs, see Table 4). The study highlighted the benefits for patients with diabetes, showing a better monitoring of the disease and a smaller impact on the statin therapy indicator.^17,18 Other studies reported positive results also for patients with heart failure.¹⁹ In view of these positive results, our aim is to analyse the perspectives of GPs in terms of organizational changes and their collaboration with other professionals and with the community.

Methods

A web survey was conducted in 2015²⁰ to investigate the experiences and points of view of Tuscan GPs about several issues related to primary care organization. The questionnaire was developed according to the international literature²¹ and was adapted for the Italian context. The design of the questionnaire was shared with managers from the Tuscan Health Authority and primary care sector, and with general medicine practitioners. The questionnaire was then tested by nine GPs to validate its content and consistency. The questionnaire was structured into six macro sections with a total of 60 mandatory questions, which investigated the roles of GPs as internal actors in the health system, in terms of activities and responsibilities, and as external actors in terms of value, integration and collaboration with other professions. The sections covered the following. (1) The main characteristics of the GP, such as age, sex and number of patients, (2) activities and collaboration with other professionals, (3) experience of the regional strategies, also considering CCM, (4) Clinical governance of GPs (use and experience of the clinical governance tool, e.g. clinical guidelines, audits, targets and incentives, collaboration with colleagues, meeting and technologies) and (5) General satisfaction and a stress-free working environment. All questions had a 5-option Likert-type response. To investigate the GPs’ perspectives and opinions regarding the CCM, we ran the analysis as shown in Table 2.

Table 2.

Methodology and data analysis.

Methodology and data analysis	Part 1 The perception of GPs involved in the CCM (group 1) 619 GPs	Differences between GPs involved (group 1 619 GPs) and not involved in a CCM (group 2, 517 GPs)
Sample	Only GPs involved in a PCC	GPs both involved (group 1) and not involved in a CCM (group 2).
Questions and Likert-type scale	Five-option Likert-type responses, ranged from “no impact” (1) to “totally positive impact” (5). Responses equal to 1 show a status quo of the investigated dimension. We considered only section 3 of the questionnaire.	For satisfaction questions: 5-option Likert-type responses, ranged from “totally not satisfied” (1) to “totally satisfied” (5).For experience questions: 4-option Likert-type responses, ranged from “never” (1) to “more than three contacts a day” (4). We considered selected questions for all sections of the questionnaire, apart from section 3.
Objectives	Analysing the perceptions of the GPs in terms of the impacts of the CCM on the six core domains of the model (Table 1).	Comparing the two groups of GPs (involved and not involved in a CCM) in terms of perceptions regarding the six core domains of the model (Table 1).
Methodology	Descriptive statistics.	ANOVA analysis with Bonferroni test.

CCM: Chronic Care Model; GP: general practitioner.

The analysis included all GPs, and compared the two groups’ perspectives of the different core aspects of CCM. We thus developed a framework combining the six core aspects of the CCM, and the drivers of a successful implementation of the model. For each aspect, we used proxy variables, represented by survey questions, to measure the effects of the CCM on GPs’ perspectives. Table 3 gives the domains of CCM, questions from the survey, and the rationale behind the analysis.

Table 3.

Domains of CCM and questions used.

Rationale and proxy for the analysis	Questions from the survey only for GP’s that joined the CCM (group 1, 619 GPs)	Questions from the survey to compare GP’s joined the CCM (group I, 619 GPs) and GP’s not joined the CCM (group II, 517 GPs)
Health system and organization
Implementation climate and satisfaction for the health organization and the CCM itself at different level. This can be related also to collaboration with professionals involved in the delivery of care such as nurses, specialist and other GPs.	From 1 to 5, what is the impact of the CCM in term of relationship with nurses? From 1 to 5, what is the impact of the CCM in your experience in term of relationship with specialists?	From 1 to 5, what is you level of satisfaction in terms of collaboration with other GPs? (1 totally bad; 5 totally good) From 1 to 5, what is you level of satisfaction in terms of collaboration with nurses? (1 totally bad; 5 totally good) From 1 to 5, what is you level of satisfaction in terms of collaboration with specialists? (1 totally bad; 5 totally good)
Clinical information systems (CIS)
Needs to have readily accessible disease-specific database to facilitate and promote exchange of information between providers and patients.	From 1 to 5, what is the impact of the CCM in terms of information exchange with professionals?	In the last week, how often do you use technology tools to share clinical information with your colleagues (GPs)? (1 “never”; 5 “very often”) In the last week, how often do you use technology tools to share clinical information with specialists? (1 “never”; 5 “very often”) In the last week, how often do you use technology tools to share clinical information with the Local Health Authorities? (1 “never”; 5 “very often”)
Decision support system
Clinical and professional resource related to evidence-based guidelines, i.e. sharing of guidelines, audit, meeting for quality improvement discussion	From 1 to 5, what is the impact of the CCM in your experience in terms of appropriateness of care?	In the last year, how many times has been dedicated to the dissemination of clinical guidelines? (1 “never”; 5 “more than once a month”) In the last year, how many times has been dedicated to meeting with colleagues for quality improvements? (1 “never”; 5 “more than once a month”) From 1 to 5, how quantitative indicators can measure your practices? (1 “nothing”; 5 “totally”)
Delivery system design
Involves how care delivery services are organized, staffed and delivered. Frequency of meetings to discuss patients ‘care with colleagues both at primary and secondary care and changes in the daily activities can be considered proxies for change in the delivery system design.	From 1 to 5, what is the impact of the CCM in terms of organization of daily activities and practice?	In the last week, how often do you make contact with others GPs to discuss about patients’ care? (1 “never”; 5 “more than three contacts a day”) In the last month, how often do you make contact with nurses to discuss about patients’ care? (1 “never”; 5 “more than three contacts a day”) In the last month, how often do you make contact with specialities to discuss about patients’ care? (1 “never”; 5 “more than three contacts a day”)
Self-management support
Emphasizes patient’s role in managing health, considering patients preferences in the care process and self-management engagement. Moreover, we consider also how much the GPs stress the importance of healthy life style, a part from medical advices.	From 1 to 5, what is the impact of the CCM in terms of patient empowerment? From 1 to 5, what is the impact of the CCM in terms of quality of care of complex and fragile patient?	In general, how often do you consider patients preferences in care decision making? (1 “never”; 5 “always”) In general, to whom do you give advices on physical activities? (1 “to nobody”; 4 “every patients”)^a
Community including organizations and resources for patients
Involves linking and using community resources that support healthcare effort by clinicians. The use of church-based support groups, local community health programs, clinic-based support groups and internet are acceptable community interventions. In this sense, collaboration and engagement for social care could be considered as a proxy.	From 1 to 5, what is the impact of the CCM in terms of patient care, both health and social care?	In the last month, how often do you make contact with social workers from the community to discuss about patients’ care? (1 “never”; 5 “more than three contacts a day”) From 1 to 5, what is you level of satisfaction in terms of collaboration with social workers? (1 totally bad; 5 totally good)

CCM: Chronic Care Model; GP: general practitioner.

4 response scale: 1 – to nobody, it is not part of my job; 2 – only to those who ask for information; 3 – only to those who need; 4 to every patient.

We ran the ANOVA analysis for each variable for the two groups using the Bonferroni test. This test is a simple method that enables many comparisons to be made while still ensuring an overall confidence coefficient. The method is valid for equal and unequal sample sizes.²²

Results

GPs profile. A total of 1136 GPs responded to the survey, which was about 41% of the total. Of these, 619 (54.5%) had joined the CCM. Their average age was 59 years, and 457 of the doctors were male (73.8%) and 162 female (26.17%). The sample of GPs in and out the CCM that answered to the survey is very similar to the regional profile of GPs that are in and out the CCM (Table 4) in terms of age and sex. As for the sample of the group 1(GPs in the CCM), the majority were male (71%) with on average 60 years old.

Table 4.

Profile of GPs in and out the CCM (survey and Tuscany Region).

	Tuscany Region					Survey
	In CCM		Out CCM		Total	In CCM (group 1)		Out CCM (group 2)		Total
	N.	%	N.	%	N.	N.	%	N.	%	N.
Male	1028	71	822	69	1850	457	74	383	74	840
Female	429	29	366	31	795	162	26	143	26	296
Age^*	60	–	59	–	–	59	–	59	–	–
Total	1457	55	1188	45	2645	619	54	517	46	1136

CCM: Chronic Care Model.

^*Average in years.

Considering the sample of GPs in the CCM (group1), almost all the GPs work in a network (“associazione”), while only 5% were not part of any form of association and had solo practices. Half of the GPs who joined the CCM have practices in urban areas, 23% in provincial cities, 22% in rural areas and about 3% (18 doctors) in isolated urban areas. Over 85% of the GPs declared they had between 1000 and 1500 patients, while only 3% had less than 500. Almost 65% of the GPs estimated that between 25% and 50% of their patients are chronic patients, while 18% estimated that between 50% and 75% of their patients are chronic. Of the GPs that had joined the CCM, 58% had been involved in the CCM for more than two years.

The impact of the CCM. According to the GPs, the CCM has contributed to substantially improving the assistance to chronic patients both in terms of taking charge and of the quality of care: over 50% of GPs declared that the CCM has had a totally positive or almost totally positive impact on these aspects, while for less than 10% of doctors, there was no impact.

The project also contributed very positively in terms of empowerment of patients, with a positive benefit found for about 45% of GPs. In terms of improving the organization of outpatient daily work, the CCM had a very positive impact for about 36% of GPs, while for about 29% the CCM had no or minimal impact. When considering the relationship with other professionals, both in terms of collaboration and information exchange, the CCM contributed to improving the relationship with local nurses, but it appeared to have very poor impact on the relationship with specialist doctors. Over 50% of physicians declared that the CCM had a very positive specific influence on the relationship with nurses, while in the case of specialists, a positive or totally positive impact was declared by 22%. In terms of information exchange, over 50% of GPs stressed that the CCM did not contribute to improving the exchange of information.

In terms of overall satisfaction, GPs were asked to assess the CCM on a scale of 1 to 5, where 1 indicates “not at all satisfied” and 5 indicates “totally satisfied”. At a regional level, 45% of the GPs reported good or excellent satisfaction (scale 4 or 5), while only 6% reported a totally negative judgment (scale 1). GPs who were involved in the project for more than one year reported they were more satisfied, while characteristics such as age, sex or place of the practices had no influence on the overall satisfaction level.

Comparing GPs in and not in the CCM. The ANOVA analysis of variance also revealed a number of significant differences between the two groups. Table 4 shows for each variable the average for the two GP groups (GPs involved in a CCM as group 1 and GPs not involved as group 2) and for all GPs. We found that GPs involved in a CCM had a higher level of satisfaction or a better experience in some of the core elements of the CCM. However, there were no statistically significant differences between the two groups in terms of other elements, as shown in Table 5. Compared results of the two groups for each CCM's domains are reported in Table 6.

Decision support system. GPs involved in a CCM reported that they met more frequently to discuss quality improvements and to share clinical guidelines than GPs not involved in a CCM, and the differences between the two groups were statistically significant for all the selected issues. The frequency of both types of meeting for clinical audits was higher among GPs working in the CCM. Considering the trust in quantitative measures to assess the performance of their care, GPs involved in the CCM have more confidence than the other group; however, the confidence is quite low for both groups.

Delivery system design. In terms of the delivery system, we compared the two groups by considering how often GPs made contact (through meetings, mailing or phone calls) with other professionals, such as nurses, other GPs and specialists. For all three professions, the two groups gave statistically different results, and group 1 had a higher frequency of contacts. However, the frequency is still very low. Both groups appeared to have more contact with nurses (2.01 out of 5 for the GPs in the CCM) and less contact with specialists (1.8 out of 5 for the GPs in the CCM).

Clinical information system. The use of technology to share clinical data among professionals was quite low for both GP groups. However, the difference between the groups is statistically significant, and the gap between the two is particularly high if we consider sharing data with other GPs or with the Local Health Authorities: GPs share the clinical data more frequently if they are in the CCM. However, when considering the clinical data exchange with specialists, there are no statistical differences and the frequency is very low in both groups (2 out of 5).

Health system and organization. We considered the satisfaction of collaboration with some professionals to assess the perceptions of the GPs in both groups. The collaboration with nurses was generally reported to be positive (3.73 out of 5). On the contrary, the collaboration with specialists was perceived to be quite difficult for both the GP groups, and the CCM had no statistically significant impact on either of the two professions (nurses and specialists).

Self-management support. Regarding how often GPs consider the patients’ perspective in the decision making process, both groups perceived that they had a high involvement of patients, and the CCM appeared to improve the level of involvement (3.39 out of 5 for the whole GP sample). The importance of self-management was identified by the question related to advice on lifestyle (physical activities), which was also positive for both groups with no differences (3.64 out of 5 for the whole GP sample).

Community. We considered how often GPs meet other professionals, such as social workers from the community. In general, this involvement is quite low (1.35 out of 5 for the whole GP sample), and there is no statistically significant gap between the groups. The collaboration with social workers, as another proxy for engagement of resources from the community, was perceived as quite difficult by both the GP groups, and working in the CCM had no positive impact on the GPs’ collaboration with these professionals.

Table 5.

Impact of the CCM for GPs involved (group 1).

From 1 to 5, what is the impact of the CCM on following issues?	1 No impact	2	3	4	5 Totally positive impact
Organization of daily activities and practice	12.28%	16.80%	34.25%	24.23%	12.44%
Relationship with nurses	9.21%	13.25%	25.20%	30.05%	22.29%
Relationship with specialists	26.17%	23.59%	28.11%	15.35%	6.79%
Information exchange with professionals	19.55%	23.42%	29.08%	19.39%	8.56%
Quality of care for complex and fragile patients	8.56%	12.92%	26.82%	31.99%	19.71%
Appropriateness of care	6.95%	13.73%	28.11%	35.22%	15.99%
Patient empowerment	6.79%	15.19%	32.31%	31.34%	14.38%
Overallsatisfaction	6.95%	14.22%	33.60%	31.50%	13.73%

Table 6.

Results for the two GP groups (GPs involved in a PCC as group 1 and GPs not involved in a PCC as group 2) and for all GPs.

GPs’ satisfaction/perception regarding:	Mean GPs in CCM^* (619)	Mean GPs not in CCM^* (517)	F	P	All GPs (1136)
Healthcare organization
Collaboration with others GPs	3.63	3.37	13.75	0.002^a	3.51
Collaboration with nurses	3.73	3.63	2.49	0.11	3.68
Collaboration with specialists	2.82	2.77	0.79	0.37	2.79
Clinical information systems (CIS)
Use of technology to share clinical data with others GPs	2.71	2.27	25.88	<0.0001^a	2.50
Use of technology to share clinical data with specialists	2.07	2.06	0.01	0.92	2.07
Use of technology to share clinical data with the Local Health Authority	2.82	2.47	14.66	<0.0001^a	2.66
Decision support system
Meetings for quality improvement	3.02	2.57	38.21	<0.0001^a	2.81
Meetings to discuss clinical guide lines	3.19	2.81	25.96	<0.0001^a	3.01
Trust in quantitative measures (performance measures)	2.88	2.61	19.55	<0.0001^a	2.76
Delivery system design
Meetings with other GPs	1.89	1.58	41.03	<0.0001^a	1.75
Meetings with nurses	2.01	1.77	29.57	<0.0001^a	1.90
Meetings with specialists	1.80	1.68	9.20	<0.0025^a	1.75
Self-management support
Patients preferences in the care process	3.46	3.30	8.78	<0.0031^a	3.39
Advice on physical activities^b	3.66	3.61	2.09	0.14	3.64
Community
Meetings with social workers	1.35	1.34	0.06	0.80	1.35
Collaboration with social workers	2.56	2.52	0.24	0.623	2.54

CCM: Chronic Care Model; GP: general practitioner.

The averages of the two groups are statistically different with the Bonferroni Test.

4 Response scale.

^*Means of the likert scale from 1 to 5 (see table 3).

Discussion

The possible effect of the CCM model on staff perception and satisfaction is extremely important, because the work environment can be difficult due to the shortages of physician and nursing staff, and because of the significant health and social needs of patients. As many authors have suggested, CDM ‘demonstration projects suggest that organizational and individual readiness for change are often overestimated, that the magnitude and time frame for CDM changes are often underestimated, and that many are seriously undercapitalized’.²³ In this context, analysing GPs perspectives on the core elements of the CCM is crucial to understanding the drivers of successful change, both in terms of organizational change and quality of care improvements. The results lead to three main points of discussion.

The first concerns the GPs’ experiences and perceptions of the effects of the CCM in all the considered questions. For all the variables considered, we observed a positive difference, even where the perception was already high or if the considered issues were the same. The analysis thus revealed that no marked deterioration or discontent has occurred in any area, according to the GPs. Measures of provider satisfaction are important in the disease management of patients: ensuring provider satisfaction is crucial for the success of a DMP, which must be sensitive to the particular relationship between patients and their physicians, and to the risk of antagonizing providers.²⁴ As other studies suggest, the participation in DMP may relieve burnout in GPs, particularly as measured by emotional exhaustion.²⁵ In our study, this positive experience is confirmed by the benefits of the CCM both in terms of overall satisfaction and of improvements in daily practices.

The second issue is related to the differences found in terms of the six core elements of the CCM. The results show positive differences between the two groups of GPs, but these are very high in some cases and quite low in others (though still significant). The greatest differences (with the highest F values) are related to two core aspects of the CCM: the decision support system and the clinical information system. Statistical differences are related to the frequency of meetings to discuss quality improvement or clinical guidelines. Our results confirmed the effect of DMP on increasing professionals’ adherence to guidelines.²⁶ Thus, we may assume that the CCM can be associated with the development of clinical governance tools and attitudes, related to the use of governance and quality tools.

Education of health professionals alone was not found to improve patient health outcomes, but clinical information systems that provide audits and feedback encourage the use of decision support. Chronic disease registers are also important in CDM, in terms of patient identification and the planning of regular follow-ups.²⁶

GPs in the CCM had a higher level of trust in the quantitative indicators of the quality of GPs work using performance measures. This is related to the set of measures the Tuscany Region uses to assess the CCM and to set incentives for the GPs. However, even though the difference was positive, the trust in indicators remains quite low (2.88 out of 5). As Dennis et al.²⁵ found, the feeling of being ‘watched’ can lead to GPs’ sense of professionalism being undermined, which can be demotivating for professionals in general. Taking part in the DMP can provide the opportunity to reflect on the organization and on what the regional healthcare system offers, not only at a micro level between GPs, but also at a macro level.^9,26

The results of the other core elements of the CCM differ. Both community resources and self-management support have positive statistically significant differences for the GPs involved in the CCM. However, the difference is quite small, as is the F value. In terms of health organization, we found no statistical difference with regard the collaborations with other professionals, i.e. nurses and specialists. The collaboration between nurses and GPs in both groups was quite positive, but the impact of the CCM on the collaboration with specialists was weak, and both groups reported a low level of satisfaction regarding this aspect. The collaboration between GPs and specialists has important implications for healthcare systems, particularly if the GP is the gatekeeper to specialist care. The low perceived level of collaboration between GPs and specialists in the Tuscan CCM appears to confirm that a DMP does not automatically lead to a more integrated collaboration between primary and secondary care, as confirmed by other studies.^9,27,28 This study confirmed that in the CCM the work is often in distinct silos, not only because it considers single diseases, but also because professionals appear to perceive the boundaries between professions are strong.^29,30 This can also be related to the poor perception of both groups on using technology to share clinical data among professionals: even if the F value is statistically significant, the frequency of technology use is quite low in both groups. A timely exchange of appropriate information among healthcare professionals has been identified as a prerequisite for care coordination,²⁸ so we can assume that the clinical information system (measured by our proxy related to information exchange) is important both in terms of improving patient care and in encouraging professionals’ integration. In terms of self-management, the results show a positive difference in considering the patients’ preferences in the decision-making process of the clinical pathway, even with good satisfaction but a low F value. However, advising on physical activities does not differ between the groups, and the level of performance is good for both GPs in and out the CCM. As Wagner et al. underlined,³⁰ one essential element of effective chronic illness care is productive interaction, unlike current interaction that can be frustrating for both patients and providers. Productive interaction thus consists of providing both systematic, evidence-based chronic disease care and collaborative goal-setting and problem-solving, which results in a shared care plan.

Community resources aim to help patients’ access effective and useful services and resources in the surrounding community. Taking into account the GPs perspectives, we measured the level of collaboration with social professionals, as there are many important resources and services for patients that are not part of most medical systems, such as peer support groups, exercise programs, educators, dieticians and social assistance. The differences in community resources were not significant, and the resulting levels are quite low, both for collaboration (2.56 out of 5) and frequency of meeting (1.35 out of 5) with social workers. These results confirm that there is in general a difficult relationship between social workers and GPs, even where a DMP is put in place. Social workers are not specifically mentioned in most CCMs. However, as the health and social care processes can become complicated if the individual encounters barriers to partnering roles necessitated by CCMs, a role for the social worker should be more clearly defined. Studies have confirmed the need for a clear social work role, so GPs can work collaboratively with other health professionals within a CCM.³¹

Limitations

The study presents some limitations. First, the study was carried out among a group of adopters who had voluntarily joined the CCM. Such contest may represent favourable pre-conditions, especially for GPs’ satisfaction and perception of the CCM implementation. However, the analysis compares the differences between Group 1 and Group 2, and is based on experience and routine of the daily work of the GPs. This analysis tests the core aspects of CCM in the two groups, and the results do not necessarily confirm the hypothesis of different chronic management, such as the collaboration with specialists. Moreover, evaluations and analysis of intervention studies are often limited to information provided by program participants, with little or nothing is known about non-participants.³² Our analysis considers the two perspectives. As Eccles et al.¹³ underline, given the current limited state of empirical testing of any theory with healthcare professionals, it is more informative to measure the actual behaviour whenever this is possible.

We only considered the experience of GPs and the data were self-reported by the respondents. Despite the acknowledgment of the role of organisational factors on DMP experiences, we focused on the perceptions of GPs as an innovative approach to the analysis of the CCM core aspects. Given that the results are based on a single case study over a limited period, they are not easily generalizable. However, the study was designed to be easily replicated in other contexts, particularly in similar healthcare systems, so the results and the framework of analysis can be tested. Further research could investigate the phenomenon including other variables, such as the perceptions of other staff and of patients.

Conclusion

The effects of this model must be evaluated not only in terms of quality improvement and effectiveness but also by identifying the key implementation factors leading professionals in the change, according to the perception of GPs working within this new organizational model. As Magnezi et al. state³³:

implementing DMPs requires organizational change. […] staff might be afraid of change and will need reassurance that DMPs will not compromise their professional status or prestige. The key for success is the inclusion and collaboration of all parties in the implementation process, enabling them to overcome perceived barriers.

The factors identified as related to professional satisfaction in implementing DMP as CCM offer valuable insights into where organizational efforts should be directed to improve integration, clinical governance and care. Three main conclusions can be drawn from the results:

The CCM requires a framework of analysis that also considers the experience and satisfaction of involved staff, with a multidimensional integrated perspective. The experience of GPs is crucial, as their working methods are influenced by the new model. The analysis thus underlines the need for long-term and tangible commitment to the change, which consider relational (i.e. perceived collaboration) and formal (i.e. quality improvement tools) conditions, and how these conditions are perceived by the GPs.

The six core elements of the CCM are not all positively associated with the implementation of the model itself. The CCM may have a positive effect on the tools for quality improvements and the culture, but not on changes in the delivery system design or on collaboration among professionals.

By considering internal and external drivers, the case study highlights the difficulties in increasing external resources from the community in addition to patient engagement. DMPs may thus reveal a weakness, from the GPs’ perspectives, in the drivers that they have less control over.

Primary care transformation represents a complex system redesign requiring a policy environment that aligns payment and training to support the work. It also requires organizations, in which leaders, managers, and care providers are highly engaged in achieving change. This study provides a detailed investigation of the implementation of DMPs, by considering the professional point of view and it helps to bridging the knowledge-to-practice gap.

Footnotes

Acknowledgement

The authors wish to thanks all the GPs involved in the study and the research of the Laboratorio Management e Sanità involved in the research.

Authors' contributions

Author 1 designed the study and the survey, analysed and interpreted the data of the survey and was the major contributor in writing the manuscript. Author 2 revised the article. All authors read and approved the final version of the article.

Availability of data and material

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Health Department of the Tuscany Region funded the research.

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