title: Exploring the variation in implementation of a COPD disease management programme and its impact on health outcomes: a post hoc analysis of the RECODE cluster randomised trial.
abstract: This study aims to (1) examine the variation in implementation of a 2-year chronic obstructive pulmonary disease (COPD) management programme called RECODE, (2) analyse the facilitators and barriers to implementation and (3) investigate the influence of this variation on health outcomes. Implementation variation among the 20 primary-care teams was measured directly using a self-developed scale and indirectly through the level of care integration as measured with the Patient Assessment of Chronic Illness Care (PACIC) and the Assessment of Chronic Illness Care (ACIC). Interviews were held to obtain detailed information regarding the facilitators and barriers to implementation. Multilevel models were used to investigate the association between variation in implementation and change in outcomes. The teams implemented, on average, eight of the 19 interventions, and the specific package of interventions varied widely. Important barriers and facilitators of implementation were (in)sufficient motivation of healthcare provider and patient, the high starting level of COPD care, the small size of the COPD population per team, the mild COPD population, practicalities of the information and communication technology (ICT) system, and hurdles in reimbursement. Level of implementation as measured with our own scale and the ACIC was not associated with health outcomes. A higher level of implementation measured with the PACIC was positively associated with improved self-management capabilities, but this association was not found for other outcomes. There was a wide variety in the implementation of RECODE, associated with barriers at individual, social, organisational and societal level. There was little association between extent of implementation and health outcomes.
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.|Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
authors.forename: Melinde R S
authors.initials: MR
authors.lastname: Boland
authors.affiliation: Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Annemarije L
authors.initials: AL
authors.lastname: Kruis
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.|Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
authors.forename: Simone A
authors.initials: SA
authors.lastname: Huygens
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.|Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.|Health Economics Research Centre, Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Apostolos
authors.initials: A
authors.lastname: Tsiachristas
authors.affiliation: Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
authors.forename: Willem J J
authors.initials: WJ
authors.lastname: Assendelft
authors.affiliation: Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Jacobijn
authors.initials: J
authors.lastname: Gussekloo
authors.affiliation: Zorgdraad Foundation, Wijnand van Arnhemweg 54, Oosterbeek, The Netherlands.
authors.forename: Coert M G
authors.initials: CM
authors.lastname: Blom
authors.affiliation: Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Niels H
authors.initials: NH
authors.lastname: Chavannes
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.|Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
authors.forename: Maureen P M H
authors.initials: MP
authors.lastname: Rutten-van Mölken
mesh_terms: D000368:Aged; D019468:Disease Management; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D055361:Multilevel Analysis; D010043:Outcome and Process Assessment, Health Care; D026741:Physical Therapy Modalities; D011320:Primary Health Care / Q000458:organization & administration*; D029424:Pulmonary Disease, Chronic Obstructive / Q000534:rehabilitation*; D012648:Self Care; D016540:Smoking Cessation