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Table 1 Characteristics of the of the Pfizer-FRQS-MSSS funded programs

From: The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting

Program Sites Target population Health professionals in interdisciplinary team Basis for self-management program Study design Evaluation method
P1. Implementation and evaluation of an integrated primary care network for prevention and management of chronic pain 4 CSSS Inclusion: low back pain <1 year, exclusion: severe dependence, mental of cognitive problems; Covered by CSST or SAAQ Doctor, nurse, psychologist, physiotherapist Stanford model 5A program Quasi-experimental multiple pretest/posttest interrupted time series Mixed methods (triangulation): qualitative (multiple case study) and quantitative
P2. Evaluation of an integrated primary care network for prevention and management for cardiometabolic risk in Montreal 6 CSSS Inclusion: marginal fasting glycemia, or glucose intolerance, or diabetes treated with diet only, or diabetes treated with monotherapie, or diabetes treated with more than one medication if HbA1c ≤8.0 %; as well as adults with hypertension with BP in the doctor’s office ≥140/90 (if diabetic, with BP ≥130/80) Nurse, psychologist (or social worker), kinesiologist, nutritionist, pharmacist   Quasi-experimental multiple pretest/posttest interrupted time series Mixed methods (triangulation): qualitative (multiple case study) and quantitative
P3. TRANSforming InTerprofessional clinical practices to improve cardiovascular disease prevention in primary care [10, 11] 8 FMG Inclusion: multimorbid patients with moderate to high cardiovascular risk Doctor, nurse, pharmacist, and either a nutritionist, kinesiologist, or psychologist   Randomized trial NCT01418716 Development: Participatory research
Impact: qualitative and quantitative, with triangulation
P4. SIID2: intersectoral and interdisciplinary management of type 2 diabetes (http://www.siid2.ca) 1 RLS Inclusion: 45 years+, all patients at-risk of diabetes (screened with CANRISK) or with diabetes Doctor, nurse, kinesiologist, social worker, nutritionist, pharmacist, CCM Randomized trial Quantitative (impact and implementation)
Survey
Exclusion: Pregnancy, institutionalized patients, cognitive deficit
P5. PR1MaC: evaluating the integration of chronic disease prevention and management services into primary health care [12] 2 CSSS Inclusion: patients aged 18 and 75 years with at least one of the following conditions: diabetes, cardiovascular disease, COPD, asthma or risk factors (smoking, obesity, dyslipidemia, glucose intolerance, and metabolic syndrome, sedentarity) Nurse, kinesiologist, nutritionist, smoking cessation therapist, respiratory therapist CCM, Stanford Randomized trial with delayed intervention arm, before-and-after design with repeated measures, and quasi-experimental design using a comparative cohort NCT01319656 Realist evaluation and practical participatory approach (implementation)
Quantitative (impact)
Exclusion: patients with serious cognitive problems
P6. VISAGES: implementation and evaluation of a pragmatic intervention of case management and self-management support for frequent users [13] 2 CSSS Inclusion: high users of hospital services, aged 18–80 years with diabetes, cardiovascular disease, respiratory diseases, musculoskeletal diseases and/or chronic pain Doctor, nurse, psychologist, social worker, kinesiologist, nutritionist, pharmacist Stanford model Implementation analysis, Randomized trial with delayed intervention arm NCT01719991 Realist evaluation and practical participatory approach (implementation)
Exclusion: severe mental health or cognitive problems
4 FMG
Qualitative and quantitative (impact)
Cost-effectiveness and cost-benefit analysis
Economic analysis
P7. Self management of health within the territory of Rocher-percé 2 CSSS Inclusion: patients aged 18 and over with ≥1 chronic conditions (diabetes, COPD, cardiovascular disease, kidney failure) and related risk factors (obesity, hypercholesterolemia, HT etc.) Nurse, kinesiologist, nutritionist Home made Quasi-experimental multiple pretest/posttest interrupted time series Collaborative research with developmental approach
Mixed methods for efficacy (triangulation): qualitative and quantitative
Qualitative (implementation)
Exclusion: severe dependence, cognitive problems, decompensated cardiac insufficiency, stage 3–4 COPD, Severe uncontrolled HT
  1. CSSS health and social service centres, FMG family medicine group, CSST health and occupational safety commission, SAAQ automobile insurance society of Quebec, COPD chronic obstructive pulmonary disease, RLS local service network