title: Implementation of chronic illness care in German primary care practices--how do multimorbid older patients view routine care? A cross-sectional study using multilevel hierarchical modeling.
abstract: BACKGROUND
  In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views.
  
  
  METHODS
  This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice).
  
  
  RESULTS
  The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice.
  
  
  CONCLUSIONS
  This study shows that from the perspective of multimorbid patients receiving care in German primary care practices, the implementation of structured care and counseling could be improved, particularly by helping patients set specific goals, coordinating care, and arranging follow-up contacts. Studies evaluating chronic care should take into consideration that a patient's assessment is associated not only with practice-level factors, but also with individual, patient-level factors.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN89818205.
authors.affiliation: Institute of General Practice, Goethe-University Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt/Main 60590, Germany. petersen@allgemeinmedizin.uni-frankfurt.de.
authors.forename: Juliana J
authors.initials: JJ
authors.lastname: Petersen
authors.forename: Michael A
authors.initials: MA
authors.lastname: Paulitsch
authors.forename: Karola
authors.initials: K
authors.lastname: Mergenthal
authors.forename: Jochen
authors.initials: J
authors.lastname: Gensichen
authors.forename: Heike
authors.initials: H
authors.lastname: Hansen
authors.forename: Siegfried
authors.initials: S
authors.lastname: Weyerer
authors.forename: Steffi G
authors.initials: SG
authors.lastname: Riedel-Heller
authors.forename: Angela
authors.initials: A
authors.lastname: Fuchs
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Maier
authors.forename: Horst
authors.initials: H
authors.lastname: Bickel
authors.forename: Hans-Helmut
authors.initials: HH
authors.lastname: König
authors.forename: Birgitt
authors.initials: B
authors.lastname: Wiese
authors.forename: Hendrik
authors.initials: H
authors.lastname: van den Bussche
authors.forename: Martin
authors.initials: M
authors.lastname: Scherer
authors.forename: Anne
authors.initials: A
authors.lastname: Dahlhaus
mesh_terms: D002908:Chronic Disease / Q000628:therapy*; D015897:Comorbidity; D003430:Cross-Sectional Studies; D019317:Evidence-Based Medicine; D005260:Female; D005858:Germany / Q000453:epidemiology; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D010147:Pain Measurement; D011320:Primary Health Care / Q000458:organization & administration*; D011446:Prospective Studies; D011787:Quality of Health Care; D011788:Quality of Life; D020377:Self Efficacy; D012944:Social Support; D011795:Surveys and Questionnaires
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