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easuring chronic care management ex
easuring chronic care management experience of patients with diabetes: PACIC and PACIC+ validation
Hanneke W Drewes, MSc, PhD, Student, Janneke T de Jong-van Til, MSc, Researcher, Jeroen N Struijs, PhD, Senior Researcher, Caroline A Baan, PhD, Senior Researcher, Fetene B Tekle, PhD, Statician, Bert R Meijboom, PhD, Senior Researcher, and G.P Westert, Director IQ Healthcare/Professor of Health Services Research
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Abstract
Background
The patient assessment of chronic illness care (PACIC) is a promising instrument to evaluate the chronic care experiences of patients, yet additional validation is needed to improve its usefulness.
Methods
A total of 1941 patients with diabetes completed the questionnaire. Reliability coefficients and factor analyses were used to psychometrically test the PACIC and PACIC+ (i.e. PACIC extended with six additional multidisciplinary team functioning items to improve content validity). Intra-class correlations were computed to identify the extent to which variation in scores can be attributed to GP practices.
Results
The PACIC and PACIC+ showed a good psychometric quality (Cronbach’s alpha’s >0.9). Explorative factor analyses showed inconclusive results. Confirmative factor analysis showed that none of the factor structures had an acceptable fit (RMSEA>0.10). In addition, 5.1 to 5.4% of the total variation was identified at the GP practice level.
Conclusion
The PACIC and PACIC+ are reliable instruments to measure the chronic care management experiences of patients. The PACIC+ is preferred because it also includes multidisciplinary coordination and cooperation—one of the central pillars of chronic care management—with good psychometric quality. Previously identified subscales should be used with caution. Both PACIC instruments are useful in identifying GP practice variation.
Keywords: chronic care model, patient experience, chronic care management, integrated care, diabetes, PACIC
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Background
Chronic care management for patients with diabetes has changed in recent decades. Initiatives such as multidisciplinary protocols, pro-active care plans, and additional education have been introduced [1, 2]. Most of these initiatives are in line with the widely adopted chronic care model (CCM) [2]. The CCM is promoted as a guide to improve chronic care to realise patient-centred care in which problems such as fragmentation, guideline non-adherence, and restricted self-management are limited [3, 4]. Because patient-centredness is becoming more and more important in chronic care, it is of importance to measure the chronic care experiences of patients [5]. Patients’ chronic care experience is positively related to other aspects of health care quality, including their engagement with and adherence to provider’s instructions as well as clinical processes and outcomes [6]. Moreover, patients’ experiences can be used for quality improvement or even as a benchmark tool [5–9].
Several instruments exist to measure patient’s chronic care experiences [9]. The Patient Assessment of Chronic Illness Care (PACIC), which measures the extent of alignment of chronic care with the CCM, is one of the most promising instruments to measure patients’ chronic care experience [8–11]. Previous studies suggest that PACIC scores can be used to direct quality improvement programs [8–11].
Notwithstanding the promising results from previous studies, additional validation of the PACIC is needed to improve this instrument [9, 11–13]. First, it is still unknown which PACIC subscales are appropriate to use. Previous validation studies, with the exception of the recently performed validation by Gugiu, used inappropriate methodological tests for PACIC’s ordinal data structure [12, 13]. Gugiu validated the PACIC with a modified response scale to avoid an ordinal structure; however, this modified response scale was unsuccessful [12, 13].
Second, the PACIC is assumed to measure the extent to which chronic care, for instance diabetes care, is congruent with the CCM. However, not all components of the CCM are fully taken into account. In particular, the functioning of the multidisciplinary team, i.e. collaboration and coordination, is only briefly mentioned in the PACIC. Additional team-functioning items would increase the content validity because the CCM assumes that interventions on the practice level aim to improve the functioning of the pro-active multidisciplinary team and thereby the quality of chronic care management.
Third, as far as we know, it has not yet been determined if and how the PACIC could be used to compare the quality of chronic care between GP practices. Dutch GP practices, including GPs and GP practice nurses working at the same address, provide diabetes care collaboratively. Patients’ experiences of chronic care management within a GP practice could be useful as a marketing tool [5]; however, it is unknown whether the PACIC identifies differences in patients’ experiences between GP practices. As patients’ perspective ratings on the quality of chronic care could only be reliably interpreted by case-mix adjustment, insight into the influence at the GP practice level and individual characteristics is needed [14, 15].
Although the PACIC is considered to be the most appropriate instrument to measure patients’ chronic care experience [9], several questions need to be answered to improve its usefulness. The objectives of this study are the following: 1) to assess the psychometric quality of the PACIC using the appropriate psychometric tests for ordinal data; 2) to assess the psychometric quality of the PACIC+, that is, the PACIC including six additional multidisciplinary team functioning variables; and 3) to test the ability of the PACIC and PACIC+ to discriminate between GP practices.
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Theory and methods
Study population
Data were obtained from an observational study evaluating the effects of a bundled payment system for diabetes care in the Netherlands. Details about this study are reported elsewhere [16]. For the observational study, ten different care groups were selected based on size, catchment area, geographical location and composition (e.g. rural vs. urban), and their organisational structure. Care groups are legal entities—formed by multiple care providers often exclusively GPs—which operate as contracting entities to cover a full range of diabetes care services for a fixed period. Care groups can decide to either deliver the various diabetes care components themselves or subcontract other care providers [17]. The characteristics of the included care groups are outlined in Appendix 1.
As part of the observational study, a questionnaire was sent to a random sample of 4377 diabetes patients clustered within a random sample of 78 GP practices representing eight care groups. The people that receive their diabetes care by the GP practices are predominantly people with diabetes type 2. The goal of the questionnaire was to assess the patients’ experiences with chronic care, and it incorporated questions about demographic and clinical patient characteristics, the PACIC+, and patient outcomes. The first three authors sent the questionnaires to the patients. After three weeks, reminders were sent to non-respondents.
Measures
The PACIC was used to identify the extent to which the chronic care was congruent with Wagner’s CCM in the past 12 months. The PACIC consists of 20 questions with response categories ranging from 1 ‘almost never’ to 5 ‘almost always’, with higher scores indicating a higher extent to which patients received integrated care following the CCM elements [8]. We used the Dutch PACIC translated by Vrijhoef et al. [9]. Glasgow et al. identified five subscales of the PACIC: 1) Patient activation (3 items), 2) Delivery system design/Decision support (3 items), 3) Goal setting (5 items), 4) Problem solving/Contextual counselling (4 items), and 5) Follow-up/Coordination (5 items) [8]. The subscores for each scale were computed by averaging across items completed within that scale, and the overall PACIC was scored by averaging scores across all subscales.
Furthermore, the PACIC was upgraded by including six additional questions regarding multidisciplinary team functioning, i.e. collaboration and coordination, which are used in the Dutch consumer quality index (CQ-index) instrument [18, 19] and the Dutch panel of chronic illnesses [20]. The CQ-index instruments were developed in the Netherlands to assess the quality of care based on the American Consumer Assessment of Health care Providers and Systems (CAHPS) and the Dutch Quality of Care Through the Patient’s Eye (QUOTE) [14, 18]. The scores on these six additional items have identical response categories and scores as the PACIC. The 20 items of the PACIC and the 6 additional items of the PACIC+ are outlined in Appendix 2.
The demographic and clinical patient characteristics included in the study were age, sex, ethnicity, educational level, type of diabetes, duration of diabetes, and co-morbidity. Ethnicity was defined as Western (North-America, EU (except Turkey), Japan, Indonesia) and non-Western, and education was defined as low (lower vocational or less education), middle (secondary education), and high (higher education).
Analysis
Descriptive analyses were applied to describe the baseline characteristics of our study population. The psychometric quality of the PACIC and PACIC+ was measured by reliability and factor analysis. The reliability was tested by assessing the internal consistencies with the Cronbach’s alpha. A Cronbach’s alpha of 0.80 or higher was accepted as a good score [21]. The factor analysis included an explorative factor analysis (EFA) and confirmatory factor analysis (CFA) using the split-half method. After splitting the data-file randomly, we performed EFA with the first half. Three types of EFA were
Hanneke W Drewes, MSc, PhD, Student, Janneke T de Jong-van Til, MSc, Researcher, Jeroen N Struijs, PhD, Senior Researcher, Caroline A Baan, PhD, Senior Researcher, Fetene B Tekle, PhD, Statician, Bert R Meijboom, PhD, Senior Researcher, and G.P Westert, Director IQ Healthcare/Professor of Health Services Research
Author information ► Article notes ► Copyright and License information ►
Go to:
Abstract
Background
The patient assessment of chronic illness care (PACIC) is a promising instrument to evaluate the chronic care experiences of patients, yet additional validation is needed to improve its usefulness.
Methods
A total of 1941 patients with diabetes completed the questionnaire. Reliability coefficients and factor analyses were used to psychometrically test the PACIC and PACIC+ (i.e. PACIC extended with six additional multidisciplinary team functioning items to improve content validity). Intra-class correlations were computed to identify the extent to which variation in scores can be attributed to GP practices.
Results
The PACIC and PACIC+ showed a good psychometric quality (Cronbach’s alpha’s >0.9). Explorative factor analyses showed inconclusive results. Confirmative factor analysis showed that none of the factor structures had an acceptable fit (RMSEA>0.10). In addition, 5.1 to 5.4% of the total variation was identified at the GP practice level.
Conclusion
The PACIC and PACIC+ are reliable instruments to measure the chronic care management experiences of patients. The PACIC+ is preferred because it also includes multidisciplinary coordination and cooperation—one of the central pillars of chronic care management—with good psychometric quality. Previously identified subscales should be used with caution. Both PACIC instruments are useful in identifying GP practice variation.
Keywords: chronic care model, patient experience, chronic care management, integrated care, diabetes, PACIC
Go to:
Background
Chronic care management for patients with diabetes has changed in recent decades. Initiatives such as multidisciplinary protocols, pro-active care plans, and additional education have been introduced [1, 2]. Most of these initiatives are in line with the widely adopted chronic care model (CCM) [2]. The CCM is promoted as a guide to improve chronic care to realise patient-centred care in which problems such as fragmentation, guideline non-adherence, and restricted self-management are limited [3, 4]. Because patient-centredness is becoming more and more important in chronic care, it is of importance to measure the chronic care experiences of patients [5]. Patients’ chronic care experience is positively related to other aspects of health care quality, including their engagement with and adherence to provider’s instructions as well as clinical processes and outcomes [6]. Moreover, patients’ experiences can be used for quality improvement or even as a benchmark tool [5–9].
Several instruments exist to measure patient’s chronic care experiences [9]. The Patient Assessment of Chronic Illness Care (PACIC), which measures the extent of alignment of chronic care with the CCM, is one of the most promising instruments to measure patients’ chronic care experience [8–11]. Previous studies suggest that PACIC scores can be used to direct quality improvement programs [8–11].
Notwithstanding the promising results from previous studies, additional validation of the PACIC is needed to improve this instrument [9, 11–13]. First, it is still unknown which PACIC subscales are appropriate to use. Previous validation studies, with the exception of the recently performed validation by Gugiu, used inappropriate methodological tests for PACIC’s ordinal data structure [12, 13]. Gugiu validated the PACIC with a modified response scale to avoid an ordinal structure; however, this modified response scale was unsuccessful [12, 13].
Second, the PACIC is assumed to measure the extent to which chronic care, for instance diabetes care, is congruent with the CCM. However, not all components of the CCM are fully taken into account. In particular, the functioning of the multidisciplinary team, i.e. collaboration and coordination, is only briefly mentioned in the PACIC. Additional team-functioning items would increase the content validity because the CCM assumes that interventions on the practice level aim to improve the functioning of the pro-active multidisciplinary team and thereby the quality of chronic care management.
Third, as far as we know, it has not yet been determined if and how the PACIC could be used to compare the quality of chronic care between GP practices. Dutch GP practices, including GPs and GP practice nurses working at the same address, provide diabetes care collaboratively. Patients’ experiences of chronic care management within a GP practice could be useful as a marketing tool [5]; however, it is unknown whether the PACIC identifies differences in patients’ experiences between GP practices. As patients’ perspective ratings on the quality of chronic care could only be reliably interpreted by case-mix adjustment, insight into the influence at the GP practice level and individual characteristics is needed [14, 15].
Although the PACIC is considered to be the most appropriate instrument to measure patients’ chronic care experience [9], several questions need to be answered to improve its usefulness. The objectives of this study are the following: 1) to assess the psychometric quality of the PACIC using the appropriate psychometric tests for ordinal data; 2) to assess the psychometric quality of the PACIC+, that is, the PACIC including six additional multidisciplinary team functioning variables; and 3) to test the ability of the PACIC and PACIC+ to discriminate between GP practices.
Go to:
Theory and methods
Study population
Data were obtained from an observational study evaluating the effects of a bundled payment system for diabetes care in the Netherlands. Details about this study are reported elsewhere [16]. For the observational study, ten different care groups were selected based on size, catchment area, geographical location and composition (e.g. rural vs. urban), and their organisational structure. Care groups are legal entities—formed by multiple care providers often exclusively GPs—which operate as contracting entities to cover a full range of diabetes care services for a fixed period. Care groups can decide to either deliver the various diabetes care components themselves or subcontract other care providers [17]. The characteristics of the included care groups are outlined in Appendix 1.
As part of the observational study, a questionnaire was sent to a random sample of 4377 diabetes patients clustered within a random sample of 78 GP practices representing eight care groups. The people that receive their diabetes care by the GP practices are predominantly people with diabetes type 2. The goal of the questionnaire was to assess the patients’ experiences with chronic care, and it incorporated questions about demographic and clinical patient characteristics, the PACIC+, and patient outcomes. The first three authors sent the questionnaires to the patients. After three weeks, reminders were sent to non-respondents.
Measures
The PACIC was used to identify the extent to which the chronic care was congruent with Wagner’s CCM in the past 12 months. The PACIC consists of 20 questions with response categories ranging from 1 ‘almost never’ to 5 ‘almost always’, with higher scores indicating a higher extent to which patients received integrated care following the CCM elements [8]. We used the Dutch PACIC translated by Vrijhoef et al. [9]. Glasgow et al. identified five subscales of the PACIC: 1) Patient activation (3 items), 2) Delivery system design/Decision support (3 items), 3) Goal setting (5 items), 4) Problem solving/Contextual counselling (4 items), and 5) Follow-up/Coordination (5 items) [8]. The subscores for each scale were computed by averaging across items completed within that scale, and the overall PACIC was scored by averaging scores across all subscales.
Furthermore, the PACIC was upgraded by including six additional questions regarding multidisciplinary team functioning, i.e. collaboration and coordination, which are used in the Dutch consumer quality index (CQ-index) instrument [18, 19] and the Dutch panel of chronic illnesses [20]. The CQ-index instruments were developed in the Netherlands to assess the quality of care based on the American Consumer Assessment of Health care Providers and Systems (CAHPS) and the Dutch Quality of Care Through the Patient’s Eye (QUOTE) [14, 18]. The scores on these six additional items have identical response categories and scores as the PACIC. The 20 items of the PACIC and the 6 additional items of the PACIC+ are outlined in Appendix 2.
The demographic and clinical patient characteristics included in the study were age, sex, ethnicity, educational level, type of diabetes, duration of diabetes, and co-morbidity. Ethnicity was defined as Western (North-America, EU (except Turkey), Japan, Indonesia) and non-Western, and education was defined as low (lower vocational or less education), middle (secondary education), and high (higher education).
Analysis
Descriptive analyses were applied to describe the baseline characteristics of our study population. The psychometric quality of the PACIC and PACIC+ was measured by reliability and factor analysis. The reliability was tested by assessing the internal consistencies with the Cronbach’s alpha. A Cronbach’s alpha of 0.80 or higher was accepted as a good score [21]. The factor analysis included an explorative factor analysis (EFA) and confirmatory factor analysis (CFA) using the split-half method. After splitting the data-file randomly, we performed EFA with the first half. Three types of EFA were
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easuring mãn tính chăm sóc quản lý kinh nghiệm của bệnh nhân với bệnh tiểu đường: PACIC và PACIC + xác nhậnHanneke W Drewes, Thạc sĩ, tiến sĩ, học sinh, Janneke T de Jong-van Til, MSc, nhà nghiên cứu, Jeroen N Struijs, tiến sĩ, nhà nghiên cứu cao cấp, Caroline A Baan, tiến sĩ, nhà nghiên cứu cao cấp, Fetene B Khan, tiến sĩ, Statician, Bert R Meijboom, tiến sĩ, nhà nghiên cứu cao cấp, và G.P Westert, giám đốc IQ y tế/giáo sư nghiên cứu dịch vụ y tếTác giả thông tin ► bài viết ghi chú ► bản quyền và giấy phép thông tin ►Đi tới:Tóm tắtNềnViệc đánh giá bệnh nhân chăm sóc bệnh mãn tính (PACIC) là một công cụ hứa hẹn để đánh giá những kinh nghiệm chăm sóc mãn tính của bệnh nhân, nhưng xác nhận bổ sung cần thiết để cải thiện tính hữu dụng của nó.Phương phápTổng cộng năm 1941 bệnh nhân với bệnh tiểu đường hoàn thành các câu hỏi. Hệ số độ tin cậy và yếu tố phân tích được sử dụng để psychometrically kiểm tra các PACIC và PACIC + (tức là PACIC mở rộng với sáu đội đa ngành bổ sung chức năng mục để cải thiện tính hợp lệ nội dung). Mối tương quan duyên hải bên trong lớp được tính toán để xác định mức độ mà các biến thể điểm có thể được quy cho GP thực hành.Kết quảCác PACIC và PACIC + cho thấy một chất lượng tốt psychometric (Cronbach của alpha > 0,9). Explorative yếu tố phân tích cho thấy kết quả không quyết định. Confirmative yếu tố phân tích cho thấy rằng không ai trong số các yếu tố cấu trúc bị một chấp nhận được (RMSEA > 0,10). Ngoài ra, 5.1 để 5,4% của các biến thể tất cả đã được xác định ở mức độ thực hành GP.Kết luậnCác PACIC và PACIC + là các công cụ đáng tin cậy để đo lường những kinh nghiệm quản lý chăm sóc mãn tính của bệnh nhân. PACIC + được ưa thích bởi vì nó cũng bao gồm đa ngành phối hợp và hợp tác-một trong những trụ cột trung tâm của mãn tính chăm sóc quản lý-với chất lượng tốt psychometric. Trước đó được xác định subscales nên được dùng thận trọng. Cả hai công cụ PACIC là hữu ích trong việc xác định sự thay đổi thực hành của GP.Từ khoá: mô hình chăm sóc mãn tính, bệnh nhân kinh nghiệm, mãn tính chăm sóc quản lý, tích hợp chăm sóc, bệnh tiểu đường, PACICĐi tới:NềnMãn tính chăm sóc quản lý cho bệnh nhân tiểu đường đã thay đổi trong thập kỷ gần đây. Các sáng kiến như đa ngành giao thức, kế hoạch chủ động chăm sóc và giáo dục bổ sung đã được giới thiệu [1, 2]. Hầu hết những sáng kiến là phù hợp với mô hình nuôi rộng rãi chăm sóc mãn tính (CCM) [2]. CCM đang xúc tiến như một hướng dẫn để cải thiện kinh niên chăm sóc để nhận ra bệnh nhân Trung tâm chăm sóc trong những vấn đề như phân mảnh, hướng dẫn phòng không tuân thủ, và hạn chế tự quản lý được giới hạn [3, 4]. Bởi vì bệnh nhân-centredness đang trở nên quan trọng hơn và nhiều hơn nữa trong việc chăm sóc mãn tính, nó là quan trọng để đo lường những kinh nghiệm chăm sóc mãn tính của bệnh nhân [5]. Bệnh nhân mãn tính chăm sóc kinh nghiệm tích cực liên quan đến các khía cạnh khác của chất lượng chăm sóc sức khỏe, bao gồm sự tham gia với và tuân thủ các hướng dẫn của nhà cung cấp cũng như quy trình lâm sàng và các kết quả [6]. Hơn nữa, kinh nghiệm bệnh nhân có thể được sử dụng để cải thiện chất lượng hoặc thậm chí là một công cụ điểm chuẩn [5-9].Nhiều nhạc cụ tồn tại để đo kinh nghiệm chăm sóc mãn tính của bệnh nhân [9]. Các bệnh nhân đánh giá của mãn tính bệnh tật chăm sóc (PACIC), mà các biện pháp trong phạm vi của sự liên kết của các chăm sóc mãn tính với CCM, là một trong các công cụ hứa hẹn nhất để đo kinh nghiệm mãn tính chăm sóc bệnh nhân [8-11]. Nghiên cứu trước đây cho thấy rằng điểm số PACIC có thể được dùng để chuyển các chương trình cải tiến chất lượng [8-11].Bất kể kết quả đầy hứa hẹn từ các nghiên cứu trước đây, các xác nhận bổ sung của PACIC là cần thiết để cải thiện các nhạc cụ này [9, 11-13]. Trước tiên, đó là vẫn còn chưa biết đó PACIC subscales được thích hợp để sử dụng. Nghiên cứu xác nhận trước đây, ngoại trừ xác nhận mới thực hiện bởi Gugiu, sử dụng bài kiểm tra phương pháp không thích hợp cho các cấu trúc dữ liệu tự của PACIC [12, 13]. Gugiu xác nhận PACIC với quy mô lần phản ứng để tránh một cấu trúc tự; Tuy nhiên, quy mô lần phản ứng này đã không thành công [12, 13].Thứ hai, PACIC cho để đo lường mức độ mà chăm sóc mãn tính, ví dụ chăm sóc bệnh tiểu đường, là đồng dư với CCM. Tuy nhiên, không phải tất cả các thành phần của CCM đầy đủ được đưa vào tài khoản. Đặc biệt, các hoạt động của nhóm đa ngành, nghĩa là sự hợp tác và phối hợp, chỉ một thời gian ngắn đã đề cập trong PACIC. Bổ sung đội ngũ hoạt động mục sẽ tăng tính xác thực nội dung vì CCM giả định rằng các can thiệp vào mức độ thực hành nhằm mục đích để cải thiện các chức năng của đội đa ngành chủ động và do đó chất lượng quản lý chăm sóc mãn tính.Thứ ba, như xa như chúng ta biết, nó đã không vẫn chưa được xác định nếu và làm thế nào PACIC có thể được sử dụng để so sánh chất lượng chăm sóc mãn tính giữa GP thực tiễn. Hà Lan GP thực hành, bao gồm GPs và bác sĩ gia đình thực hành y tá làm việc tại cùng một địa chỉ, cung cấp chăm sóc bệnh tiểu đường cộng tác. Bệnh nhân kinh nghiệm mãn tính chăm sóc quản lý trong một bác sĩ gia đình thực hành có thể hữu ích như một công cụ tiếp thị [5]; Tuy nhiên, nó là không rõ liệu PACIC xác định sự khác biệt trong bệnh nhân kinh nghiệm giữa GP thực tiễn. Khi bệnh nhân quan điểm xếp hạng về chất lượng chăm sóc mãn tính chỉ có thể được giải thích đáng tin cậy bởi trường hợp-trộn điều chỉnh, cái nhìn sâu sắc ảnh hưởng tại GP thực hành cấp và đặc điểm cá nhân cần thiết [14, 15].Mặc dù PACIC được coi là công cụ thích hợp nhất để đo kinh nghiệm mãn tính chăm sóc bệnh nhân [9], một số câu hỏi cần được trả lời để cải thiện tính hữu dụng của nó. Mục tiêu của nghiên cứu này là như sau: 1) để đánh giá chất lượng psychometric của PACIC bằng cách sử dụng các bài kiểm tra psychometric thích hợp cho dữ liệu tự; 2) để đánh giá chất lượng psychometric của các PACIC +, có nghĩa là, PACIC trong đó có sáu đội đa ngành bổ sung chức năng biến; và 3) để kiểm tra khả năng của PACIC và PACIC + phân biệt đối xử giữa GP thực tiễn.Đi tới:Lý thuyết và phương phápNghiên cứu dânData were obtained from an observational study evaluating the effects of a bundled payment system for diabetes care in the Netherlands. Details about this study are reported elsewhere [16]. For the observational study, ten different care groups were selected based on size, catchment area, geographical location and composition (e.g. rural vs. urban), and their organisational structure. Care groups are legal entities—formed by multiple care providers often exclusively GPs—which operate as contracting entities to cover a full range of diabetes care services for a fixed period. Care groups can decide to either deliver the various diabetes care components themselves or subcontract other care providers [17]. The characteristics of the included care groups are outlined in Appendix 1.As part of the observational study, a questionnaire was sent to a random sample of 4377 diabetes patients clustered within a random sample of 78 GP practices representing eight care groups. The people that receive their diabetes care by the GP practices are predominantly people with diabetes type 2. The goal of the questionnaire was to assess the patients’ experiences with chronic care, and it incorporated questions about demographic and clinical patient characteristics, the PACIC+, and patient outcomes. The first three authors sent the questionnaires to the patients. After three weeks, reminders were sent to non-respondents.MeasuresThe PACIC was used to identify the extent to which the chronic care was congruent with Wagner’s CCM in the past 12 months. The PACIC consists of 20 questions with response categories ranging from 1 ‘almost never’ to 5 ‘almost always’, with higher scores indicating a higher extent to which patients received integrated care following the CCM elements [8]. We used the Dutch PACIC translated by Vrijhoef et al. [9]. Glasgow et al. identified five subscales of the PACIC: 1) Patient activation (3 items), 2) Delivery system design/Decision support (3 items), 3) Goal setting (5 items), 4) Problem solving/Contextual counselling (4 items), and 5) Follow-up/Coordination (5 items) [8]. The subscores for each scale were computed by averaging across items completed within that scale, and the overall PACIC was scored by averaging scores across all subscales.Furthermore, the PACIC was upgraded by including six additional questions regarding multidisciplinary team functioning, i.e. collaboration and coordination, which are used in the Dutch consumer quality index (CQ-index) instrument [18, 19] and the Dutch panel of chronic illnesses [20]. The CQ-index instruments were developed in the Netherlands to assess the quality of care based on the American Consumer Assessment of Health care Providers and Systems (CAHPS) and the Dutch Quality of Care Through the Patient’s Eye (QUOTE) [14, 18]. The scores on these six additional items have identical response categories and scores as the PACIC. The 20 items of the PACIC and the 6 additional items of the PACIC+ are outlined in Appendix 2.The demographic and clinical patient characteristics included in the study were age, sex, ethnicity, educational level, type of diabetes, duration of diabetes, and co-morbidity. Ethnicity was defined as Western (North-America, EU (except Turkey), Japan, Indonesia) and non-Western, and education was defined as low (lower vocational or less education), middle (secondary education), and high (higher education).AnalysisDescriptive analyses were applied to describe the baseline characteristics of our study population. The psychometric quality of the PACIC and PACIC+ was measured by reliability and factor analysis. The reliability was tested by assessing the internal consistencies with the Cronbach’s alpha. A Cronbach’s alpha of 0.80 or higher was accepted as a good score [21]. The factor analysis included an explorative factor analysis (EFA) and confirmatory factor analysis (CFA) using the split-half method. After splitting the data-file randomly, we performed EFA with the first half. Three types of EFA were
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easuring chronic care management experience of patients with diabetes: PACIC and PACIC+ validation
Hanneke W Drewes, MSc, PhD, Student, Janneke T de Jong-van Til, MSc, Researcher, Jeroen N Struijs, PhD, Senior Researcher, Caroline A Baan, PhD, Senior Researcher, Fetene B Tekle, PhD, Statician, Bert R Meijboom, PhD, Senior Researcher, and G.P Westert, Director IQ Healthcare/Professor of Health Services Research
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Abstract
Background
The patient assessment of chronic illness care (PACIC) is a promising instrument to evaluate the chronic care experiences of patients, yet additional validation is needed to improve its usefulness.
Methods
A total of 1941 patients with diabetes completed the questionnaire. Reliability coefficients and factor analyses were used to psychometrically test the PACIC and PACIC+ (i.e. PACIC extended with six additional multidisciplinary team functioning items to improve content validity). Intra-class correlations were computed to identify the extent to which variation in scores can be attributed to GP practices.
Results
The PACIC and PACIC+ showed a good psychometric quality (Cronbach’s alpha’s >0.9). Explorative factor analyses showed inconclusive results. Confirmative factor analysis showed that none of the factor structures had an acceptable fit (RMSEA>0.10). In addition, 5.1 to 5.4% of the total variation was identified at the GP practice level.
Conclusion
The PACIC and PACIC+ are reliable instruments to measure the chronic care management experiences of patients. The PACIC+ is preferred because it also includes multidisciplinary coordination and cooperation—one of the central pillars of chronic care management—with good psychometric quality. Previously identified subscales should be used with caution. Both PACIC instruments are useful in identifying GP practice variation.
Keywords: chronic care model, patient experience, chronic care management, integrated care, diabetes, PACIC
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Background
Chronic care management for patients with diabetes has changed in recent decades. Initiatives such as multidisciplinary protocols, pro-active care plans, and additional education have been introduced [1, 2]. Most of these initiatives are in line with the widely adopted chronic care model (CCM) [2]. The CCM is promoted as a guide to improve chronic care to realise patient-centred care in which problems such as fragmentation, guideline non-adherence, and restricted self-management are limited [3, 4]. Because patient-centredness is becoming more and more important in chronic care, it is of importance to measure the chronic care experiences of patients [5]. Patients’ chronic care experience is positively related to other aspects of health care quality, including their engagement with and adherence to provider’s instructions as well as clinical processes and outcomes [6]. Moreover, patients’ experiences can be used for quality improvement or even as a benchmark tool [5–9].
Several instruments exist to measure patient’s chronic care experiences [9]. The Patient Assessment of Chronic Illness Care (PACIC), which measures the extent of alignment of chronic care with the CCM, is one of the most promising instruments to measure patients’ chronic care experience [8–11]. Previous studies suggest that PACIC scores can be used to direct quality improvement programs [8–11].
Notwithstanding the promising results from previous studies, additional validation of the PACIC is needed to improve this instrument [9, 11–13]. First, it is still unknown which PACIC subscales are appropriate to use. Previous validation studies, with the exception of the recently performed validation by Gugiu, used inappropriate methodological tests for PACIC’s ordinal data structure [12, 13]. Gugiu validated the PACIC with a modified response scale to avoid an ordinal structure; however, this modified response scale was unsuccessful [12, 13].
Second, the PACIC is assumed to measure the extent to which chronic care, for instance diabetes care, is congruent with the CCM. However, not all components of the CCM are fully taken into account. In particular, the functioning of the multidisciplinary team, i.e. collaboration and coordination, is only briefly mentioned in the PACIC. Additional team-functioning items would increase the content validity because the CCM assumes that interventions on the practice level aim to improve the functioning of the pro-active multidisciplinary team and thereby the quality of chronic care management.
Third, as far as we know, it has not yet been determined if and how the PACIC could be used to compare the quality of chronic care between GP practices. Dutch GP practices, including GPs and GP practice nurses working at the same address, provide diabetes care collaboratively. Patients’ experiences of chronic care management within a GP practice could be useful as a marketing tool [5]; however, it is unknown whether the PACIC identifies differences in patients’ experiences between GP practices. As patients’ perspective ratings on the quality of chronic care could only be reliably interpreted by case-mix adjustment, insight into the influence at the GP practice level and individual characteristics is needed [14, 15].
Although the PACIC is considered to be the most appropriate instrument to measure patients’ chronic care experience [9], several questions need to be answered to improve its usefulness. The objectives of this study are the following: 1) to assess the psychometric quality of the PACIC using the appropriate psychometric tests for ordinal data; 2) to assess the psychometric quality of the PACIC+, that is, the PACIC including six additional multidisciplinary team functioning variables; and 3) to test the ability of the PACIC and PACIC+ to discriminate between GP practices.
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Theory and methods
Study population
Data were obtained from an observational study evaluating the effects of a bundled payment system for diabetes care in the Netherlands. Details about this study are reported elsewhere [16]. For the observational study, ten different care groups were selected based on size, catchment area, geographical location and composition (e.g. rural vs. urban), and their organisational structure. Care groups are legal entities—formed by multiple care providers often exclusively GPs—which operate as contracting entities to cover a full range of diabetes care services for a fixed period. Care groups can decide to either deliver the various diabetes care components themselves or subcontract other care providers [17]. The characteristics of the included care groups are outlined in Appendix 1.
As part of the observational study, a questionnaire was sent to a random sample of 4377 diabetes patients clustered within a random sample of 78 GP practices representing eight care groups. The people that receive their diabetes care by the GP practices are predominantly people with diabetes type 2. The goal of the questionnaire was to assess the patients’ experiences with chronic care, and it incorporated questions about demographic and clinical patient characteristics, the PACIC+, and patient outcomes. The first three authors sent the questionnaires to the patients. After three weeks, reminders were sent to non-respondents.
Measures
The PACIC was used to identify the extent to which the chronic care was congruent with Wagner’s CCM in the past 12 months. The PACIC consists of 20 questions with response categories ranging from 1 ‘almost never’ to 5 ‘almost always’, with higher scores indicating a higher extent to which patients received integrated care following the CCM elements [8]. We used the Dutch PACIC translated by Vrijhoef et al. [9]. Glasgow et al. identified five subscales of the PACIC: 1) Patient activation (3 items), 2) Delivery system design/Decision support (3 items), 3) Goal setting (5 items), 4) Problem solving/Contextual counselling (4 items), and 5) Follow-up/Coordination (5 items) [8]. The subscores for each scale were computed by averaging across items completed within that scale, and the overall PACIC was scored by averaging scores across all subscales.
Furthermore, the PACIC was upgraded by including six additional questions regarding multidisciplinary team functioning, i.e. collaboration and coordination, which are used in the Dutch consumer quality index (CQ-index) instrument [18, 19] and the Dutch panel of chronic illnesses [20]. The CQ-index instruments were developed in the Netherlands to assess the quality of care based on the American Consumer Assessment of Health care Providers and Systems (CAHPS) and the Dutch Quality of Care Through the Patient’s Eye (QUOTE) [14, 18]. The scores on these six additional items have identical response categories and scores as the PACIC. The 20 items of the PACIC and the 6 additional items of the PACIC+ are outlined in Appendix 2.
The demographic and clinical patient characteristics included in the study were age, sex, ethnicity, educational level, type of diabetes, duration of diabetes, and co-morbidity. Ethnicity was defined as Western (North-America, EU (except Turkey), Japan, Indonesia) and non-Western, and education was defined as low (lower vocational or less education), middle (secondary education), and high (higher education).
Analysis
Descriptive analyses were applied to describe the baseline characteristics of our study population. The psychometric quality of the PACIC and PACIC+ was measured by reliability and factor analysis. The reliability was tested by assessing the internal consistencies with the Cronbach’s alpha. A Cronbach’s alpha of 0.80 or higher was accepted as a good score [21]. The factor analysis included an explorative factor analysis (EFA) and confirmatory factor analysis (CFA) using the split-half method. After splitting the data-file randomly, we performed EFA with the first half. Three types of EFA were
Hanneke W Drewes, MSc, PhD, Student, Janneke T de Jong-van Til, MSc, Researcher, Jeroen N Struijs, PhD, Senior Researcher, Caroline A Baan, PhD, Senior Researcher, Fetene B Tekle, PhD, Statician, Bert R Meijboom, PhD, Senior Researcher, and G.P Westert, Director IQ Healthcare/Professor of Health Services Research
Author information ► Article notes ► Copyright and License information ►
Go to:
Abstract
Background
The patient assessment of chronic illness care (PACIC) is a promising instrument to evaluate the chronic care experiences of patients, yet additional validation is needed to improve its usefulness.
Methods
A total of 1941 patients with diabetes completed the questionnaire. Reliability coefficients and factor analyses were used to psychometrically test the PACIC and PACIC+ (i.e. PACIC extended with six additional multidisciplinary team functioning items to improve content validity). Intra-class correlations were computed to identify the extent to which variation in scores can be attributed to GP practices.
Results
The PACIC and PACIC+ showed a good psychometric quality (Cronbach’s alpha’s >0.9). Explorative factor analyses showed inconclusive results. Confirmative factor analysis showed that none of the factor structures had an acceptable fit (RMSEA>0.10). In addition, 5.1 to 5.4% of the total variation was identified at the GP practice level.
Conclusion
The PACIC and PACIC+ are reliable instruments to measure the chronic care management experiences of patients. The PACIC+ is preferred because it also includes multidisciplinary coordination and cooperation—one of the central pillars of chronic care management—with good psychometric quality. Previously identified subscales should be used with caution. Both PACIC instruments are useful in identifying GP practice variation.
Keywords: chronic care model, patient experience, chronic care management, integrated care, diabetes, PACIC
Go to:
Background
Chronic care management for patients with diabetes has changed in recent decades. Initiatives such as multidisciplinary protocols, pro-active care plans, and additional education have been introduced [1, 2]. Most of these initiatives are in line with the widely adopted chronic care model (CCM) [2]. The CCM is promoted as a guide to improve chronic care to realise patient-centred care in which problems such as fragmentation, guideline non-adherence, and restricted self-management are limited [3, 4]. Because patient-centredness is becoming more and more important in chronic care, it is of importance to measure the chronic care experiences of patients [5]. Patients’ chronic care experience is positively related to other aspects of health care quality, including their engagement with and adherence to provider’s instructions as well as clinical processes and outcomes [6]. Moreover, patients’ experiences can be used for quality improvement or even as a benchmark tool [5–9].
Several instruments exist to measure patient’s chronic care experiences [9]. The Patient Assessment of Chronic Illness Care (PACIC), which measures the extent of alignment of chronic care with the CCM, is one of the most promising instruments to measure patients’ chronic care experience [8–11]. Previous studies suggest that PACIC scores can be used to direct quality improvement programs [8–11].
Notwithstanding the promising results from previous studies, additional validation of the PACIC is needed to improve this instrument [9, 11–13]. First, it is still unknown which PACIC subscales are appropriate to use. Previous validation studies, with the exception of the recently performed validation by Gugiu, used inappropriate methodological tests for PACIC’s ordinal data structure [12, 13]. Gugiu validated the PACIC with a modified response scale to avoid an ordinal structure; however, this modified response scale was unsuccessful [12, 13].
Second, the PACIC is assumed to measure the extent to which chronic care, for instance diabetes care, is congruent with the CCM. However, not all components of the CCM are fully taken into account. In particular, the functioning of the multidisciplinary team, i.e. collaboration and coordination, is only briefly mentioned in the PACIC. Additional team-functioning items would increase the content validity because the CCM assumes that interventions on the practice level aim to improve the functioning of the pro-active multidisciplinary team and thereby the quality of chronic care management.
Third, as far as we know, it has not yet been determined if and how the PACIC could be used to compare the quality of chronic care between GP practices. Dutch GP practices, including GPs and GP practice nurses working at the same address, provide diabetes care collaboratively. Patients’ experiences of chronic care management within a GP practice could be useful as a marketing tool [5]; however, it is unknown whether the PACIC identifies differences in patients’ experiences between GP practices. As patients’ perspective ratings on the quality of chronic care could only be reliably interpreted by case-mix adjustment, insight into the influence at the GP practice level and individual characteristics is needed [14, 15].
Although the PACIC is considered to be the most appropriate instrument to measure patients’ chronic care experience [9], several questions need to be answered to improve its usefulness. The objectives of this study are the following: 1) to assess the psychometric quality of the PACIC using the appropriate psychometric tests for ordinal data; 2) to assess the psychometric quality of the PACIC+, that is, the PACIC including six additional multidisciplinary team functioning variables; and 3) to test the ability of the PACIC and PACIC+ to discriminate between GP practices.
Go to:
Theory and methods
Study population
Data were obtained from an observational study evaluating the effects of a bundled payment system for diabetes care in the Netherlands. Details about this study are reported elsewhere [16]. For the observational study, ten different care groups were selected based on size, catchment area, geographical location and composition (e.g. rural vs. urban), and their organisational structure. Care groups are legal entities—formed by multiple care providers often exclusively GPs—which operate as contracting entities to cover a full range of diabetes care services for a fixed period. Care groups can decide to either deliver the various diabetes care components themselves or subcontract other care providers [17]. The characteristics of the included care groups are outlined in Appendix 1.
As part of the observational study, a questionnaire was sent to a random sample of 4377 diabetes patients clustered within a random sample of 78 GP practices representing eight care groups. The people that receive their diabetes care by the GP practices are predominantly people with diabetes type 2. The goal of the questionnaire was to assess the patients’ experiences with chronic care, and it incorporated questions about demographic and clinical patient characteristics, the PACIC+, and patient outcomes. The first three authors sent the questionnaires to the patients. After three weeks, reminders were sent to non-respondents.
Measures
The PACIC was used to identify the extent to which the chronic care was congruent with Wagner’s CCM in the past 12 months. The PACIC consists of 20 questions with response categories ranging from 1 ‘almost never’ to 5 ‘almost always’, with higher scores indicating a higher extent to which patients received integrated care following the CCM elements [8]. We used the Dutch PACIC translated by Vrijhoef et al. [9]. Glasgow et al. identified five subscales of the PACIC: 1) Patient activation (3 items), 2) Delivery system design/Decision support (3 items), 3) Goal setting (5 items), 4) Problem solving/Contextual counselling (4 items), and 5) Follow-up/Coordination (5 items) [8]. The subscores for each scale were computed by averaging across items completed within that scale, and the overall PACIC was scored by averaging scores across all subscales.
Furthermore, the PACIC was upgraded by including six additional questions regarding multidisciplinary team functioning, i.e. collaboration and coordination, which are used in the Dutch consumer quality index (CQ-index) instrument [18, 19] and the Dutch panel of chronic illnesses [20]. The CQ-index instruments were developed in the Netherlands to assess the quality of care based on the American Consumer Assessment of Health care Providers and Systems (CAHPS) and the Dutch Quality of Care Through the Patient’s Eye (QUOTE) [14, 18]. The scores on these six additional items have identical response categories and scores as the PACIC. The 20 items of the PACIC and the 6 additional items of the PACIC+ are outlined in Appendix 2.
The demographic and clinical patient characteristics included in the study were age, sex, ethnicity, educational level, type of diabetes, duration of diabetes, and co-morbidity. Ethnicity was defined as Western (North-America, EU (except Turkey), Japan, Indonesia) and non-Western, and education was defined as low (lower vocational or less education), middle (secondary education), and high (higher education).
Analysis
Descriptive analyses were applied to describe the baseline characteristics of our study population. The psychometric quality of the PACIC and PACIC+ was measured by reliability and factor analysis. The reliability was tested by assessing the internal consistencies with the Cronbach’s alpha. A Cronbach’s alpha of 0.80 or higher was accepted as a good score [21]. The factor analysis included an explorative factor analysis (EFA) and confirmatory factor analysis (CFA) using the split-half method. After splitting the data-file randomly, we performed EFA with the first half. Three types of EFA were
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