Patient Assessment Of Chronic Illness Care Research Articles

Impact of the Chronic Care Model on medication adherence when patients perceive cost as a barrier

AimsCost burdens represent a significant barrier to medication adherence among chronically ill patients, yet financial pressures may be mitigated by clinical or organizational factors, such as treatment aligned with the Chronic Care Model (CCM). This study examines how perceptions of chronic illness care attenuate the relationship between adherence and cost burden. MethodsSurveys were administered to patients at 40 small community-based primary care practices. Medication adherence was assessed using the 4-item Morisky scale, while five cost-related items documented recent pharmacy restrictions. CCM experiences were assessed via the 20-item Patient Assessment of Chronic Illness Care (PACIC). Nested random effects models determined if chronic care perceptions modified the association between medication adherence and cost-related burden. ResultsOf 1823 respondents reporting diabetes and other chronic diseases, one-quarter endorsed intrapersonal adherence barriers, while 23% restricted medication due of cost. Controlling for age and health status, the relationship between medication cost and CCM with adherence was significant; including PACIC scores attenuated cost-related problems patients with adequate or problematic adherence behavior. ConclusionsPatients experiencing treatment more consistent with the CCM reported better adherence and lower cost-related burden. Fostering highly activated patients and shared clinical decision making may help alleviate medication cost pressures and improve adherence.

Factorial validation of the patient assessment of chronic illness care (PACIC) and PACIC short version (PACIC-S) among cardiovascular disease patients in the Netherlands

ObjectiveThe Chronic Care Model (CCM) has achieved widespread acceptance and reflects the core elements of patient-centred care in chronic diseases such as cardiovascular diseases (CVD). In the Netherlands the extent to which CVD patients receive care congruent with the CCM is unknown. The main objectives of this study were to validate the 20-item Patient Assessment of Chronic Illness Care (PACIC) and the 11-item (PACIC-S) in the Netherlands among CVD patients and investigate the validity, reliability, and sensitivity to change of both instruments.MethodsThe Dutch version of the PACIC and PACIC-S were tested among 1484 CVD patients (out of 2760; response rate 54%) enrolled in Disease Management Programmes (DMPs) at T0 and 1167 respondents (out of 2545; response rate = 46%) at T1. Five hundred-eighty-five CVD patients filled in the questionnaire at both T0 and T1. We tested the instrument by means of structural equation modeling, and examined its construct validity, reliability and sensitivity to change. Reliability of the instrument was assessed by determining the statistical coherence of the scaled items. Internal consistency of the subscales was assessed by calculating Cronbach’s alphas and correlations between the PACIC and PACIC-S. We investigated the sensitivity to change of the original PACIC and the PACIC-S with paired t-tests among CVD patients in DMPs who filled in the questionnaire at both T0 and T1 (N = 585).ResultsThe confirmatory factor analyses revealed good indices of fit with the PACIC and PACIC-S. Internal consistency as represented by Cronbach’s alphas were also good. Correlations between the PACIC and PACIC-S subscales were excellent: 0.98 at both T0 and T1. Paired t-tests results show that the PACIC and PACIC-S improved significantly over time (p < 0.01).ConclusionsThe psychometric properties of the Dutch PACIC and PACIC-S were satisfactory and it is sensitive to change, rendering it a valid and reliable instrument for assessing chronic illness care among CVD patients.

Comorbidity and patient-reported quality of care: an evaluation of the primary care based German disease management program for type 2 diabetes

Previous evaluations of the German disease management program (DMP) for type 2 diabetes show that this approach curbs drug and hospital costs, may reduce mortality and improve quality of diabetes care. Otherwise until now there have been no evaluations which analyse the impact of comorbidity (COMORB) on the effectiveness of German DMP to strengthen patient-reported quality of care. Therefore, the study aimed to assess and compare the impact of comorbidity on patient-reported quality of care for patients participating in DMP and in routine care (RC). A questionnaire including the Patient Assessment of Chronic Illness Care (PACIC) was mailed to a random sample of 3,546 patients. We grouped patients according to their participation into DMP and RC. To compare groups, we performed analysis of covariance. We considered all main effects, the interaction of DMP * COMORB and assessed the estimated PACIC scores for each number of other conditions. 1,532 questionnaires were returned (42.2%). Valid data existed for 1,399 patients. The analysis showed that only participation in the DMP (p < 0.0001) and gender (p < 0.001) had an impact on the PACIC. The estimated PACIC score of patients in DMP was higher than in routine care for all numbers of other conditions. Whereas the increasing number of other conditions was associated with lower PACIC scores in DMP, it was associated with increased PACIC scores in RC. Patients with type 2 diabetes in DMP had higher PACIC scores than patients in RC, irrespective of the number of other conditions. Our study revealed no significant impact of comorbidity on the effect of German DMP on patient-reported quality of care.

Multidisciplinary Team Care Arrangements in the management of patients with chronic disease in Australian general practice

To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice. Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics. Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores. Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not. Findings were consistent with the purpose of TCAs--to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

Adaptation, data quality and confirmatory factor analysis of the Danish version of the PACIC questionnaire

The Patient Assessment of Chronic Illness Care (PACIC) 20-item questionnaire measures how chronic care patients perceive their involvement in care. We aimed to adapt the measure into Danish and to assess data quality, internal consistency and the proposed factorial structure. The PACIC was translated by a standardised forward-backward procedure, and filled in by 560 patients receiving type 2 diabetes care. Data quality was assessed by mean, median, item response, missing values, floor and ceiling effects, internal consistency (Cronbach's α and average inter-item correlation), item-rest correlations and factorial structure was assessed by confirmatory factor analysis (CFA). The item response was high (missing answers: 0.5-2.9%). Floor effect was 2.7-69.2%, above 15% for 17 items. Ceiling effect was 4.0-40.4%, above 15% for 12 items. The subscales had average inter-item correlations over 0.30 and CFA showed high factor loadings (range 0.67-0.77). All had α over 0.7 and included items with both high and low loadings. The CFA model fit was good for two indices out of six (TLI and SRMR). Danish PACIC is now available and validated in primary care in a type 2 diabetes population. The psychometric properties were satisfactory apart from ceiling and floor effects. We endorse the proposed five scale structure. All the subscales showed good model fit, and may be used for separate sum scores.

Taking the PACIC back to basics: the structure of the Patient Assessment of Chronic Illness Care

The Patient Assessment of Chronic Illness Care (PACIC) is a widely used 20-item measure consisting of five subscales. Published factor analyses of PACIC scores have produced conflicting results on the measure's factorial validity, and therefore some confusion as to the utility of its subscales. We aim to reduce this confusion by reviewing the evidence on the PACIC's factorial validity, exploring the statistical issues it raises, and considering more broadly what such analyses can reveal about the validity of the PACIC. To achieve these aims we review six published studies on the PACIC's factorial validity, present confirmatory factor analyses of our own PACIC data from 251 chronic care patients, and assess the PACIC with respect to its status as a reflective or a formative measure. Our statistical analyses support the view that a 5-factor model does not fit the structure of the PACIC, and highlight a variety of technical issues that confront researchers who wish to factor analyse the measure. However, we argue that, as the PACIC is more accurately seen as a formative measure, such analyses do not provide information that should be used to assess the PACIC's validity. We conclude that, while it is important to continue examining the reliability and validity of the PACIC in a variety of ways, traditional analyses of its factorial validity (and internal consistency) are inappropriate. Meanwhile, use of the subscales is defensible as long as they continue to meet other types of reliability and validity requirements.

Patients Assessment of Chronic Illness Care (PACIC) in two Australian studies: structure and utility

To validate the Patients Assessment of Chronic Illness Care (PACIC) among patients with chronic disease in the Australian context and to examine the relationship between patient-assessed quality of care and patient and practice characteristics. Cross-sectional analysis of baseline data in two independent health service intervention studies that involved patients with type 2 diabetes, ischaemic heart disease and/or hypertension in general practice. The first study involved 2552 patients from 60 urban and rural general practices. The second involved 989 patients from 26 practices in Sydney. Patients were mailed a questionnaire, which included the PACIC and Short Form Health Survey. Factor analysis was performed and the factor scores and total PACIC were analysed using multi-level regression models against practice and patient characteristics. Factor analysis revealed a two-factor solution with similar loading of PACIC items in both studies: one for shared decision making and self-management and the other for planned care. Practice characteristics were not related to PACIC scores. Scores were related to patient characteristics - education, retirement, type and number and duration of conditions. The two-factor structure of the PACIC found in these Australian studies is different from the five-factor structure found in the US and the European studies. This may be related to differences in the way patients interact with the health system especially the use of Team Care plans. The association of total scores with patient characteristics was consistent with those found in other studies including a lack of association with gender, age and ethnicity. These findings should be taken into consideration when comparing patient-assessed quality of care between countries using this tool.

Structure and measurement properties of the Patient Assessment of Chronic Illness Care instrument

In this study, the authors investigated the psychometric properties of a modified version of the Patient Assessment of Chronic Illness Care (PACIC) - a self-report instrument designed to measure the extent to which patients with chronic illness receive care congruent with the chronic care model. Five hundred and twenty-nine (529) type 2 diabetics were surveyed with a modified-PACIC. An exploratory and confirmatory factor analysis was conducted that accounted for the ordinal nature of the PACIC items. Ordinal alpha (0.972) and omega (0.973) reliability coefficients were calculated on the latent factor underlying the modified-PACIC. Correlation analyses were used to investigate the relationship between the modified-PACIC and numerous clinical labs related to diabetes. Validity for the original five-factor structure proposed by developers of the PACIC could not be confirmed. More research focusing on the instrument's psychometric properties is necessary before researchers use it to investigate the chronic care model and patient health. Researchers will need to ensure that the composite scores underlying the instrument are normally distributed and correlated with behavioural and health indexes.

Modifying the PACIC to assess provision of chronic illness care: An exploratory study with primary health care nurses

In line with Wagner's Chronic Care Model, the Patient Assessment of Chronic Illness Care (PACIC) has been developed to evaluate chronic illness care delivery from the patient's perspective. Modification of the instrument to assess the same aspects of care delivery from the health practitioner's perspective would enable individual practitioners to evaluate their own provision of self-management support, and would also enable a more direct comparison between care provided and care received within the chronic illness context. To explore the potential of a modified PACIC instrument to assess individual health practitioners' delivery of care to chronic illness patients with a sample of primary health care nurses. Seventy-seven primary care nurses completed the modified PACIC, reworded to ask about care provision rather than receipt of care. An additional seven cultural sensitivity items were included, as were questions about the suitability of the types of chronic illness care and who should be providing the care. The modified PACIC items appear to be appropriate for use with health practitioners. Agreement that the types of care described in the PACIC should be provided was almost unanimous, and the predominant view was that self-management support should be provided by both nurses and doctors. Mean scale scores were higher than those generally reported from studies using the PACIC. The results of this first evaluation of a modified PACIC suggest that the original items plus the cultural sensitivity items can be used to assess self-management support by individual health practitioners.

The feasibility of assessing the Flinders Programme of Patient Self-Management in New Zealand primary care settings

The Flinders Program™ has been adopted in New Zealand as a useful and appropriate approach for self-management with primary care clients who have chronic conditions. The Flinders Program™ has not been evaluated in New Zealand settings. To assess the feasibility of undertaking a substantive long-term trial to gauge the effectiveness of primary care nurses using the Flinders Program™ to improve health outcomes for New Zealand populations. A pilot study was undertaken considering four components of feasibility of conducting a long-term trial: practice recruitment, participant recruitment, delivery of the intervention and outcome measures. This included comparing 27 intervention and 30 control patients with long-term health conditions with respect to change in self-management capacity-Partners in Health (PIH) scale-quality of care using the Patient Assessment of Chronic Illness Care (PACIC) scale and self-efficacy across six months. Intervention participants received care planning with practice nurses using the Flinders Program™ in general practices, while control participants received usual care in comparable practices. General practice and participant recruitment was challenging, together with a lack of organisational capacity and resources in general practice for the Flinders Program™. The measures of self-management capacity (PIH), quality of care (PACIC) and self-efficacy were useful and valuable primary outcome measures. The overall findings do not support a substantive trial of the Flinders Program™ in primary care. Difficulties associated with participant recruitment and ability of practice nurses to undertake the Flinders Program™ within general practice need to be resolved.

Development and evaluation of the short version of the Patient Assessment of Chronic Illness Care instrument

The Patient Assessment of Chronic Illness Care (PACIC) was developed for measuring the extent to which patients receive care congruent with the chronic care model (CCM). The purpose of this study was to develop a short version of the PACIC with better psychometric properties than the original instrument. Two samples of 529 and 361 type 2 diabetic patients completed a modified PACIC. A short-version PACIC instrument was developed and validated using parallel analysis to determine the number of factors, confirmatory factor analysis (CFA) within an exploratory factor analysis framework (E/CFA) was conducted to explore the measurement structure of the full instrument, and a CFA was performed to confirm the hypothesized structure. The results demonstrated that the PACIC is unidimensional and that it can be reduced to 11 items with no loss in psychometric properties. No demographic variables or clinical assays were found to be related to the PACIC. A short-version PACIC is now available and ready for use in research with diabetic patients. Its use is encouraged in future research, particularly in the exploration of its validity against actual CCM services delivered and long-term clinical outcomes.

Effects of Guided Care on Family Caregivers

Guided Care (GC) is a model of health care for multimorbid older adults that is provided by a registered nurse who works with the patients' primary care physician (PCP). The purpose of this study was to determine whether GC improves patients' primary caregivers' depressive symptoms, strain, productivity, and perceptions of the quality of care recipients' chronic illness care. A cluster-randomized controlled trial of GC was conducted within 14 PCP teams. The study sample included 196 primary caregivers who completed baseline and 18-month surveys and whose care recipients remained alive and enrolled in the GC study for 18 months. Caregiver outcomes included the following: depressive symptoms (Center for Epidemiological Studies-Depression scale), strain (Modified Caregiver Strain Index), the quality of care recipients' chronic illness care [Patient Assessment of Chronic Illness Care (PACIC)], and personal productivity (Work Productivity and Activity Impairment questionnaire, adapted for caregiving). In multivariate regression models, between-group differences in depression, strain, work productivity, and regular activity productivity were not statistically significant after 18 months, but GC caregivers reported the overall quality of their recipients' chronic illness care to be significantly higher (adjusted beta = 0.40, 95% confidence interval : 0.14-0.67). Quality was significantly higher in 4 of 5 PACIC subscales, reflecting the dimensions of goal setting, coordination of care, decision support, and patient activation. GC improved the quality of chronic illness care received by multimorbid care recipients but did not improve caregivers' depressive symptoms, affect, or productivity.

Racial/ethnic and educational-level differences in diabetes care experiences in primary care

To assess potential racial/ethnic and educational-level differences in the degree to which patients with diabetes who receive primary care from a Veterans Affairs Medical Center report that experiences with the diabetes care system are consistent with the Chronic Care Model (CCM). A cross-sectional mailed survey of 296 patients included the Patient Assessment of Chronic Illness Care (PACIC), which measures components of the care system suggested by the CCM. Among 189 patients with complete information, non-white veterans had more than twice the odds of indicating that their diabetes care experience is in line with the CCM [measured by overall PACIC score > or =3.5] (OR 2.3; 95% CI 1.3-4.1). Non-white veterans were more likely to report high levels of assistance with problem solving and follow-up. Patients not completing high school had three times the odds of reporting care in line with the CCM (OR 3.0; 95% CI 1.2-7.6). Associations were also seen with implementation of the CCM in the areas of patient activation, perceived care teams, collaborative goal setting, and collaborative problem solving. Non-white patients and those with less than a high school education had more than twice the odds of reporting that the diabetes care system is in line with the CCM.

Use of the Patient Assessment of Chronic Illness Care (PACIC) With Diabetic Patients

There is a dearth of information on the extent to which diabetic patients receive care congruent with the chronic care model (CCM) and evidence-based behavioral counseling. This study evaluates a new instrument to fill this gap. A heterogeneous sample of 363 type 2 diabetic patients completed the original Patient Assessment of Chronic Illness Care (PACIC), along with additional items that allowed it to be scored according to the "5As" (ask, advise, agree, assist, and arrange) model of behavioral counseling. We evaluated relationships between survey scores and patient characteristics, quality of diabetes care, and self-management. Findings replicated those of the initial PACIC validation study but with a much larger sample of diabetic patients and more Latinos. Areas of CCM activities reported least often were goal setting/intervention tailoring and follow-up/coordination. The 5As scoring revealed that patients were least likely to receive assistance with problem solving and arrangement of follow-up support. Few demographic or medical characteristics were related to PACIC or 5As scores, but survey scores were significantly related to quality of diabetes care received and level of physical activity. The PACIC and the new 5As scoring method appear useful for diabetic patients. Its use is encouraged in future research and quality improvement studies.

Development and Validation of the Patient Assessment of Chronic Illness Care (PACIC)

There is a need for a brief, validated patient self-report instrument to assess the extent to which patients with chronic illness receive care that aligns with the Chronic Care Model-measuring care that is patient-centered, proactive, planned and includes collaborative goal setting; problem-solving and follow-up support. A total of 283 adults reporting one or more chronic illness from a large integrated health care delivery system were studied. Participants completed the 20-item Patient Assessment of Chronic Illness Care (PACIC) as well as measures of demographic factors, a patient activation scale, and subscales from a primary care assessment instrument so that we could evaluate measurement performance, construct, and concurrent validity of the PACIC. The PACIC consists of 5 scales and an overall summary score, each having good internal consistency for brief scales. As predicted, the PACIC was only slightly correlated with age and gender, and unrelated to education. Contrary to prediction, it was only slightly correlated (r = 0.13) with number of chronic conditions. The PACIC demonstrated moderate test-retest reliability (r = 0.58 during the course of 3 months) and was correlated moderately, as predicted (r = 0.32-0.60, median = 0.50, P < 0.001) to measures of primary care and patient activation. The PACIC appears to be a practical instrument that is reliable and has face, construct, and concurrent validity. The resulting questionnaire is in the public domain, and recommendations for its use in research and quality improvement are outlined.