NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands.
BMC Fam Pract. 2011 Jul 5;12:68. doi: 10.1186/1471-2296-12-68.
More than half of the patients with type 2 diabetes (T2DM) patients are diagnosed with one or more comorbid disorders. They can participate in several single-disease oriented disease management programs, which may lead to fragmented care because these programs are not well prepared for coordinating care between programs. Comorbid patients are therefore at risk for suboptimal treatment, unsafe care, inefficient use of health care services and unnecessary costs. Case management is a possible model to counteract fragmented care for comorbid patients. It includes evidence-based optimal care, but is tailored to the individual patients' preferences.The objective of this study is to examine the effectiveness of a case management program, in addition to a diabetes management program, on the quality of care for comorbid T2DM patients.
METHODS/DESIGN: The study is a randomized controlled trial among patients with T2DM and at least one comorbid chronic disease (N=230), who already participate in a diabetes management program. Randomization will take place at the level of the patients in general practices. Trained practice nurses (case managers) will apply a case management program in addition to the diabetes management program. The case management intervention is based on the Guided Care model and includes six elements; assessing health care needs, planning care, create access to other care providers and community resources, monitoring, coordinating care and recording of all relevant information. Patients in the control group will continue their participation in the diabetes management program and receive care-as-usual from their general practitioner and other care providers.
We expect that the case management program, which includes better structured care based on scientific evidence and adjusted to the patients' needs and priorities, will improve the quality of care coordination from both the patients' and caregivers' perspective and will result in less consumption of health care services.
Netherlands Trial Register (NTR): NTR1847.
超过一半的 2 型糖尿病（T2DM）患者被诊断出患有一种或多种合并症。他们可以参加多个单一疾病导向的疾病管理计划，但由于这些计划在协调计划之间的护理方面准备不足，可能会导致护理碎片化。因此，合并症患者面临治疗效果不佳、护理不安全、医疗服务使用效率低下和不必要的成本增加的风险。病例管理是一种可能的模式，可以对抗合并症患者的碎片化护理。它包括基于证据的最佳护理，但针对患者个体的偏好进行调整。本研究的目的是检验病例管理计划除了糖尿病管理计划外，对合并 T2DM 患者护理质量的影响。
方法/设计：该研究是一项针对已经参加糖尿病管理计划的 T2DM 患者和至少一种合并慢性疾病患者（N=230）的随机对照试验。随机化将在一般实践层面的患者中进行。经过培训的实践护士（病例管理员）将在糖尿病管理计划之外应用病例管理计划。病例管理干预措施基于指导护理模式，包括六个要素；评估医疗保健需求、规划护理、为其他护理提供者和社区资源创造途径、监测、协调护理和记录所有相关信息。对照组患者将继续参加糖尿病管理计划，并接受他们的家庭医生和其他护理提供者的常规护理。
我们预计，病例管理计划将改善患者和护理人员的护理协调质量，并减少医疗服务的消耗，因为该计划包括基于科学证据的结构化程度更高的护理，并根据患者的需求和优先级进行调整。
荷兰试验注册（NTR）：NTR1847。
