Participatory care plan for primary care patients with long-term diseases: results after a 36-month follow-up of a randomized controlled trial

BMC Health Serv Res. 2025 Apr 12;25(1):536. doi: 10.1186/s12913-025-12660-6.

ABSTRACT

BACKGROUND: A patient care plan can be one way to ensure the coordination and continuity of care, as well as the allocation of limited healthcare resources appropriately to an aging population. This study aimed to analyze any changes in health-related outcomes within and between groups of patients with a participatory patient care plan after 36 months.

METHODS: The OSUVAT study was a pragmatic randomized intervention study in a primary care setting involving 605 patients with diabetes (DM), coronary artery disease (CAD), or hypertension (HA). The intervention was a participatory structured care plan. The control was usual care. The follow-up of 12 and 36 months included 592 patients. Measurements were conducted at baseline, 12 months, and 36 months. The outcome variables were health-related quality of life, body mass index, HbA1C, LDL-cholesterol, and blood pressure. In addition, achievement of the treatment goals set by the Finnish Current Care Guidelines was assessed for blood pressure, LDL cholesterol, and HbA1C.

RESULTS: Over 36 months, there were no significant differences in all patients between the intervention and control groups. With CAD, diastolic blood pressure decreased in the intervention group by 3 mmHg (95% CI -6 to 0) whereas in the control group, it increased by 3 mmHg (95% CI 0 to 6). There was a favorable time trend for LDL cholesterol in all patients in both groups [control – 0.32 (-0.42 to -0.24), intervention – 0.39 (-0.49 to -0.30)].

CONCLUSIONS: The care plan implemented for all patients with common chronic diseases and relatively effective disease management does not appear to provide significant benefits. Patients with coronary artery disease experienced a modest benefit from the care plan in terms of blood pressure. More extensive studies of targeting care planning with different patient groups and different settings are needed.

TRIAL REGISTRATION: Clinical Trials registration number: NCT02992431, registered on December 14th, 2016.

PMID:40217248 | PMC:PMC11992695 | DOI:10.1186/s12913-025-12660-6