Introduction: Chronic disease management has become a major concern for healthcare systems in industrialized countries. There is a significant care gap between the best care, based on results from clinical trials, and usual care. Most patients with multiple chronic diseases are followed in primary care. Yet there are few tools to help primary care health professionals manage the complex care these patients require and even fewer systems that systematically assess the outcomes of care of these patients. The DaVinci system proposes a comprehensive clinical and technological approach to assist primary care interdisciplinary teams (PCITs) in the management of patients with multiple chronic problems. The project aims ultimately at improving the process of care as well as patients' health outcomes, thus helping close the healthcare gap.
Intervention: An IT-supported health-management system (DaVinci system) that gives timely, flexible access to many functionalities relevant to management of multiple chronic diseases by PCITs. At the heart of DaVinci lies the CASE (Convince, Action, Support and Empower) clinical approach, which builds on the work of Prochaska and DiClemente (1994) on readiness to change. The CASE classification helps prioritize and coordinate actions of individual team members to reach explicit, patient-centred, guideline-consistent treatment goals. The other components of the DaVinci system are: 1) a list of the patient's active chronic problems, that is, the "patient agenda," 2) explicit patient-centred treatment-goal setting for each of these problems, 3) the reason for the care gap when the treatment goal is not achieved, 4) checklists tailored to the problems identified in the agenda in order to better monitor and coordinate the provision of preventive and chronic care, 5) a virtual library with an evidence-based knowledge database, 6) a medication prescriber, 7) decision-support tools and calculators for cardiovascular risk, renal function and body mass index, 8) regular clinical performance feedback to the group and to professionals individually, and 9) a secure communication channel between team members.
Study Design: Mixed-method design. A qualitative approach using a multiple-case study design and a quantitative approach using descriptive statistics will be used to explore how the different functionalities of the DaVinci IT-supported PCIT clinical approach affect the provision and outcomes of care. Data gathered from these different approaches will be used to corroborate, validate and complement each other.
Results: The scientific data on the acceptability and integration of practice changes in primary care that will emerge from this project will contribute to the knowledge base of multimorbidity management in primary care.
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