title: Developing an active implementation model for a chronic disease management program.
abstract: BACKGROUND
  Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council's model for complex interventions and the Chronic Care Model.
  
  
  METHODS
  We used the Medical Research Council's five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model.
  
  
  RESULTS
  The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council's model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere).
  
  
  CONCLUSIONS
  The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council's model added transparency to the design phase which further facilitated the process of implementing the program.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov/(NCT01228708).
authors.affiliation: The Research Unit for General Practice Aarhus and The Section for General Medicine, Institute of Public Health, Bartholins Allé 2, Aarhus University, 8000 Aarhus C, Denmark.
authors.forename: Margrethe
authors.initials: M
authors.lastname: Smidth
authors.forename: Morten Bondo
authors.initials: MB
authors.lastname: Christensen
authors.forename: Frede
authors.initials: F
authors.lastname: Olesen
authors.forename: Peter
authors.initials: P
authors.lastname: Vedsted
keywords: Breakthrough Series; Chronic Care Model; Denmark; PaTPlot; disease management; implementation