Introduction
Establishing healthcare structures to provide better diagnosis, treatment and prevention of chronic diseases is a major challenge within the healthcare system [
1‐
3]. In order to make healthcare more effective and efficient, disease management programs (DMPs) were established in Germany in 2003 as statutory treatment programmes in the outpatient sector, especially with a focus on primary care [
4,
5]. Meanwhile, there are now more than 8 million health insurance holders enrolled in the existing DMPs, 1.2 million of whom are enrolled in more than one program [
4]. DMPs aim to better structure treatment processes and are based on current medical knowledge as well as evidence-based guidelines with regard to specifications for diagnostics and therapy [
6]. In addition, the intention is to strengthen the collaboration between the healthcare levels, for example by means of statutory job descriptions and therapy descriptions, and fixed check-up intervals [
7‐
9]. Consistent recording of all examination and treatment results serves to coordinate individual healthcare steps, so that unnecessary duplication of investigations or examinations can be avoided.
Alongside the regular care of enrolled patients, doctors who participate in DMPs receive mandatory training courses. Moreover, medical practices that offer treatment within the framework of DMPs must fulfil set quality requirements; this can lead to changes in the practice’s workflow [
10,
11]. Depending upon the program, structured training courses are also offered to patients in support of their treatment and/or for the purposes of prevention. A uniform electronic documentation system provides ongoing evaluation and quality assurance. To this end, treatment data are recorded centrally and the achieved treatment progress is fed back to participating doctors [
4,
12,
13].
It has been found that patients enrolled in DMPs are better informed about their disease and the associated risks, and display greater treatment compliance [
8,
9,
14]. However, in terms of the demonstrable effects of DMPs, there are currently very few reliable efficacy studies available for the German healthcare context. In most cases, an efficacy control is not readily possible based on the legally prescribed documentation, since there is no control group [
15]. Moreover, there are unknown disturbance variables, which can only be neutralised by strict randomisation [
1,
14,
45].
Several studies indicate favourable effects on mortality and process parameters for the type 2 diabetes DMP [
12,
16‐
22]. A multicentre but non-randomised cross-sectional study recently examined the benefit of the bronchial asthma and COPD DMPs. However, the authors were unable to prove any clinically relevant advantages for DMP participants, either in terms of disease control or quality of life [
23]. Despite the methodological limitations, an initial analysis of the effectiveness of the CHD DMP indicates positive trends in terms of mortality, cost development and guideline-based prescribing [
24]. Clinically randomised studies conducted in other countries have already demonstrated the beneficial effects of comparable programs [
18,
25‐
28].
The DMP objectives cannot be achieved without the substantial participation of general practitioners as primary care providers with access to a broad, unselected patient base [
10,
11,
22]. In this respect, general practitioners play a key role in the recruitment of patients, ensuring compliance and coordination of the treatment process [
7,
22].
Since the introduction of DMPs, there has been a controversial debate among general practitioners about the value and benefit of the structured treatment programs [
29‐
32]. One group emphasises their beneficial potential (diagnostic and therapeutic accuracy, more evidence-based practice, transparency of decision-making processes, more efficient use of resources), while another complains about excessive impacts on primary care (strict provisions that preclude individual patient care, changing of routine workflows, excessive documentation requirements) [
33].
Despite the important role that primary care plays in the DMP concept, empirical studies have only looked at it sporadically; there is a lack of up-to-date findings. In particular, there is hardly any reliable information available concerning questions of acceptance, satisfaction and the associated attitudes to and experience of DMPs in everyday primary care, especially in German-speaking countries. For example, a survey of 752 non-systematically recruited GPs shows that DMPs are judged better by primary care physicians today than shortly after their introduction. The more consistent and continuous care of chronically ill patients is seen as a clear advantage [
34]. Almost 20 years after introduction of the structured treatment programs, the present study aims to assess them from the general practitioner’s point of view.
Research interest
In order to obtain an up-to-date and broad picture of GPs’ attitudes to and experience of DMPs, a written survey was conducted among German GPs between December 2019 and March 2020. The study addressed the following questions:
-
Which DMP programs are GPs participating in?
-
What attitudes do general practitioners have towards DMPs?
-
What experiences have they had in patient care?
-
How do they rate the concrete benefit of DMPs?
-
What improvements would they like to see?
Results
Random sample
Out of a total of 1556 returned questionnaires, 1504 fully completed questionnaires were included in the evaluation. The response rate was 23%, measured against the total number of doctors contacted. The random sample is structured as follows:
-
Gender: 52% male, 48% female
-
Practice location: 45% in medium-sized towns and cities, 55% in small towns and rural areas
-
Type of practice: 55% single-handed practices, 42% group practices, 3% other
-
Patients per quarter: 18% < 1000, 29% 1000–1500, 53% > 1500
-
Average age: 55 years (median: 56)
Attitudes to and positions on DMPs
While 58% of respondents consider DMPs to be a positive element in medical care, 36% express scepticism and/or rejection (6% undecided). At a figure of 57%, the majority also say that, based on their own assessment and experience, DMPs had been of very great (14%) or fairly great (43%) benefit for patient care (27% fairly small benefit, 11% no benefit, 5% difficult to say). 37% of respondents report that their basic attitude to DMPs had significantly (15%) or slightly (22%) improved over the past few years, in 46% it has remained the same, 17% report a moderate (11%) or significant (6%) change for the worse. 43% of doctors, especially those in more rural practices, report that they have developed a greater appreciation for DMPs in recent years; among doctors in urban areas, this figure is 31% (p < 0.001).
From the respondents’ point of view, the advantages of DMPs for primary care clearly predominate (see Table
1, Overall agreement). A factor analysis was performed to obtain more accurate information about the extent to which certain views of DMPs correspond to each other.
The aim of the factor analysis is to condense a larger number of variables into factors based on systematic relationships (correlations). By condensing the variation of a plurality of variables into a much smaller number of common factors (data reduction), we tried to discover underlying common dimensions. The varimax method that was chosen for this is the most frequently used method for arriving at interpretable factorial solutions. As described in the Materials and methods section, the statistical requirements for performing the factor analysis were met.
The analysis turned out in favour of a three-factor solution, since in the present case, three factors have a disproportionately high explanatory power and in each case an eigenvalue > 1 (Kaiser criterion). In addition to this, the explained overall variance is comparatively high (65%) in a three-factor solution. Even according to the scree test, the pattern of eigenvalues most readily points to a three-factor solution. Consequently, such a structure appears to be plausible and stable. The value of 0.4/−0.4 was chosen as the limit beyond which an item loads onto a factor [
37].
In keeping with the outlined procedure, it is possible to distinguish between three clusters of GPs. The largest group notably reports perceptible progress in diagnosis, monitoring and treatment, as well as compliance effects. The stricter alignment with guidelines is perceived as a distinct advantage. Overall, a strengthening of the GP’s role is perceived. Cluster two stresses perceived negative aspects, including increased dependence on the health insurance funds or the restriction of a doctor’s therapeutic freedom. The third cluster focuses on adaptations within the practice to comply with DMP requirements.
All three groups complain about the amount of time and effort spent on documentation; overall, three quarters of all doctors point this out. Moreover, only a few of the respondents perceive an improvement in collaboration with specialist colleagues as a result of participation in one or more programmes. The doctors are doubtful about any lasting efficiency benefits in patient care due to DMPs.
DMP participation and rating
A total of 90% of respondents are currently participating in one (38%) or more (52%) DMPs; a further 5% have previously participated (5% no current or previous participation). Most of the current participants are involved in the type 2 diabetes DMP (87%), followed by the CHD DMP (86%). These are followed by the DMP for COPD (82%) and bronchial asthma (80%). 21% are participating in the DMP for type 1 diabetes, which can be explained by the specific preconditions of this program.
Based on the experience of the respondents, often covering many years, the DMP for type 2 diabetes has the best rating (39% very good, 39% fairly good). The Type 1 diabetes DMP is likewise well received by the 310 respondents participating in it (31% very good, 38% fairly good). These are followed by the DMP for CHD (23% very good, 41% fairly good), COPD (16% very good, 43% fairly good) and bronchial asthma (12% very good, 41% fairly good).
There appears to be a varying degree of acceptance of the different DMP components. For example, 85% judge the regular recall of patients, as envisaged in the intervals currently prescribed by the DMP, to be very beneficial or fairly beneficial. 73% appreciate the patient training courses that are offered in support of their treatment. 60% consider the mandatory training courses for doctors to be a very good or fairly good thing. In contrast, only 36% are satisfied with the external recording of the treatment and 32% with the current design of the documentation.
Positive and negative experiences in daily practice
1103 doctors completed the open questions provided. In the course of encoding, a number of recurring argumentation and problematisation patterns emerged. In their own words, the respondents highlight the regular patient care, the structure in patient management (therapy adherence) and the ongoing treatment monitoring as positive. Likewise, a large proportion of respondents appear to be satisfied with a better knowledge of the guidelines and the structured opportunity to attend targeted training courses.
In addition to the high amount of documentation required, difficulties in the administrative process are problematized. For example, patients who missed an appointment once are immediately removed from the program and a great amount of effort is required to re-enrol them. Other complaints were the delayed response about the participation status of patients or the fact that evaluation reports and feedback reports are submitted very late. Also, the often-unpredictable adjustment of the framework conditions of the programs impede the workflow (e.g. changing requirements and forms, changes in IT systems). Another object of criticism is the perceived lack of flexibility of the DMP design, which allegedly leaves GPs too little situational freedom of action (e.g. recall intervals, prescribing and treatment guidelines). The fact that an adequately functioning interface with other healthcare levels, in particular outpatient consultants, has not developed in pace with the DMP structures and guidelines is experienced as a huge problem. Part of the respondents criticize that health insurers exert increased pressure on patients to take part in DMPs, thereby often forcing GPs to participate in the programmes. Also, many respondents are of the opinion that patients enrolled in DMPs were not well enough informed or motivated over the longer term. Other criticisms relate to the fee structure, which many respondents think it is not proportionate to the amount of effort and extra burden in daily practice and training courses that are not always practically oriented and suited to the level of knowledge of the doctors.
Assessment and inventory of effects
Implementation of the DMP often requires a change to working practices, routines and allocation of duties in the practice. For example, 79% of respondents report that they have trained one member of their own practice staff (19%), or even several people (52%) through to the entire staff (8%), once or several times in connection with DMP participation. Irrespective of this, the changes in the everyday running of the practice caused by DMPs can, under certain circumstances, result in delays or other difficulties. Around half of the respondents participating in at least one DMP (50%) report having encountered obstacles and/or complications in their everyday practice frequently (14%) or occasionally (36%; 32% rarely, 18% never).
Despite such temporary problems and adjustments, the rest of the results indicate that the survey participants considered their involvement to be a positive thing, when they looked back. At 51%, a majority report that the treatment of the enrolled patients benefited very much (8%) or quite a lot (43%) from the DMP (30% not so much, 14% not at all, 6% it differs, difficult to say). Doctors who trained at least half their staff in the course of DMP participation are much more likely to report that the treatment of patients benefited from the DMP (61%) than doctors who only trained a few members of their staff or none all (44%; p < 0.001).
On the basis of an item set, DMP participation is clearly rated as positive overall. It is clear that the majority of respondents accept complications and extra work resulting from program participation, because they believe these are outweighed by the benefits (see Table
2). It also emerges that, in the view of the GPs, DMP participation has favourable consequences in terms of diagnostic and therapeutic procedures.
Table 2
Inventory of disease management program (DMP) participation. Question: Based on your own experience of DMPs, which of the following statements do you agree with? (N = 1426)
“The advantages of disease management programmes outweigh the disadvantages and difficulties.” | 59 | 41 |
“I essentially follow the DMP recommendations for (drug) treatment.” | 57 | 43 |
“I have improved my own skills as a result of participating in disease management programs.” | 49 | 51 |
“I can hardly imagine doing without disease management programs in my practice.” | 48 | 52 |
“I have learnt something new about diagnosis and/or treatment through participating in disease management programs.” | 44 | 56 |
Factors influencing the rating of and satisfaction with DMPs
The results of a univariant linear regression analysis reveal a series of stronger and weaker influencing factors for key dependent variables (see Table
3). As expected, the things that particularly stand out in the basic assessment of structured healthcare programmes by the respondents are positive compliance experiences (35% of overall variance, R
2) and successes in the consequent treatment of chronically ill patients (47% of overall variance, R
2). Increases in efficiency (30% of overall variance, R
2) and improvement of individual diagnostic skills (28% of overall variance, R
2) are also important reasons for the respondents giving a positive opinion of DMPs.
Table 3
General practitioners’ perception of disease management programs (DMP): univariant linear regression, identified influencing factorsa (N = 1504)
Improvement in compliance (question 4) | 0.346 | 0.346 | 795.916 | 0.544 | 0.000 | 0.506; 0.581 | 0.019 |
Restriction of therapeutic freedom (question 4) | 0.083 | 0.083 | 136.643 | −0.233 | 0.000 | −272; −0.194 | 0.02 |
Improvement in collaboration with consultants (question 4) | 0.130 | 0.129 | 224.074 | 0.289 | 0.000 | 0.251; 0.327 | 0.019 |
Strengthening the position of GPs within the healthcare process (question 4) | 0.320 | 0.319 | 705.267 | 0.513 | 0.000 | 0.475; 0.551 | 0.019 |
Preventing over- and/or undertreatment (question 4) | 0.253 | 0.253 | 509.801 | 0.405 | 0.000 | 0.369; 0.44 | 0.018 |
Clearly defined procedure in medical care (question 4) | 0.272 | 0.271 | 559.857 | 0.418 | 0.000 | 0.383; 0.452 | 0.018 |
Proactive, continuous treatment (question 4) | 0.405 | 0.405 | 1023.42 | 0.601 | 0.000 | 0.574; 0.638 | 0.019 |
Successful management of multimorbid/chronically ill patients (question 4) | 0.472 | 0.472 | 1345.378 | 0.606 | 0.000 | 0.574; 0.638 | 0.017 |
More efficient patient care (question 4) | 0.296 | 0.295 | 631.237 | 0.434 | 0.000 | 0.4; 0.468 | 0.017 |
Improvement of diagnostic skills (question 15) | 0.284 | 0.284 | 596.341 | 0.439 | 0.000 | 0.404; 0.475 | 0.018 |
New programs, prospective aspects and optimisation potential
A significant proportion of respondents are open to participating in additional DMPs that are currently in the development or implementation phase. There is a particularly high level of interest in a heart failure DMP (33% intend to participate, 40% might consider it) followed by a chronic back pain DMP (24% intend to participate, 34% might consider it).
Evaluation of a further open question indicates that the majority of respondents want to see a substantial reduction in documentation requirements for DMP in the future (e.g. dispensing with re-enrolment forms), simplifying interactions with the DMP datacentre and more organisational continuity in the treatment programs. Other frequently mentioned aspects are allowing doctors more decision-making flexibility (e.g. regarding patient recall and treatment-related decisions) as well as strengthening and better structuring of communications and/or cooperation at the interfaces with other healthcare actors. Overall, according to many respondents, DMPs should be designed with an even lower threshold for doctors and patients, thereby enabling them to play an even greater role in the care of vulnerable groups. Moreover, training courses should be more customised, offered more widely, include practice staff more than has hitherto been the case and should be free, where possible. Last but not least, the participating doctors recommend a fee structure that reflects the amount of effort, possibly by the creation of more billing codes.
From the responses, it emerges that the role of GPs should be further strengthened within the DMP design. Ways of achieving this are seen in greater GP compliance, greater orientation towards everyday application and better coordination with primary healthcare guidelines. In the spirit of a bottom-up process, GPs should have the opportunity to contribute to improvements and adaptations of the programmes, based on experience and practice. Accordingly, in a follow-up question, 80% of participants state that it would be very important or fairly important for GPs to be more involved than before in the development of new or optimisation of existing DMPs.
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