Professional commitment to changingchronic illness care: results from diseasemanagement programmesKARIN LEMMENS, MATHILDE STRATING, ROBBERT HUIJSMAN AND ANNA NIEBOER

Institute of Health Policy and Management, Erasmus University Medical Center, PO Box 1738, Rotterdam 3000 DR, The Netherlands

Abstract

Objectives. The aim of this exploratory study was to investigate to what extent primary care professionals are able to changetheir systems for delivering care to chronic obstructive pulmonary disease (COPD) patients and what professional and organ-izational factors are associated with the degree of process implementation.

Design. Quasi-experimental design with 1 year follow-up after intervention.

Setting. Three regional COPD management programmes in the Netherlands, in which general practices cooperated withregional hospitals.

Participants. All participating primary care professionals (n ¼ 52).

Intervention. COPD management programme.

Main Outcome Measures. Professional commitment, organizational context and degree of process implementation.

Results. Professionals significantly changed their systems for delivering care to COPD patients, namely self-managementsupport, decision support, delivery system design and clinical information systems. Associations were found between organiz-ational factors, professional commitment and changes in processes of care. Group culture and professional commitmentappeared to be, to a moderate degree, predictors of process implementation.

Conclusions. COPD management was effective; all processes improved significantly. Moreover, theoretically expected associ-ations between organizational context and professional factors with the implementation of COPD management were indeedconfirmed to some extent. Group culture and professional commitment are important facilitators.

Keywords: disease management, quality improvement, primary care, organizational innovation, professional practice

Introduction

Chronic diseases are the main cause of death and disabilityworldwide, and as the population ages, prevalence of chronicconditions will increase [1]. Chronic obstructive pulmonarydisease (COPD) is a common multicomponent disease thatimposes an enormous burden on the patient, medical pro-fessionals and society in terms of morbidity, mortality, healthcare resource utilization and cost [2]. Already highly preva-lent, COPD is projected to become the third most commoncause of death by 2020 [1]. Efforts to improve quality andefficiency of health care have been given high priority.Disease management, defined as ‘an approach to patient carethat emphasizes coordinated, comprehensive care along thecontinuum of disease and across health care delivery systems’

[3], has emerged as a new strategy to achieve improvement.It has three key features: it uses empowerment strategies(patient oriented) and decision support tools (professionaldirected), preferably supported by changes in the organiz-ational system [4].

A growing body of literature argues that improving thedelivery of primary care is an effective approach toimplement disease management [5, 6], as chronic illness careis largely performed within a primary care setting. Primarycare professionals are therefore at the forefront of COPDdiagnosis and management [2]. Their motivation to redesigncare is one of the keys to successful disease management[7]. However, most professionals lack the time, informationtechnology and financial resources to systematically improvethe quality of care provided to these patients [6]. There is a

Address reprint requests to: Karin Lemmens, Institute of Health Policy and Management, Erasmus University MedicalCenter, PO Box 1738, Rotterdam 3000 DR, The Netherlands. Tel: þ31-10-40-88-541; Fax: þ31-10-40-89-094;E-mail: k.lemmens@erasmusmc.nl

International Journal for Quality in Health Care

# The Author 2009. Published by Oxford University Press in association with the International Society for Quality in Health Care;

all rights reserved Page 1 of 10

International Journal for Quality in Health Care 2009; pp. 1–10 10.1093/intqhc/mzp017

International Journal for Quality in Health Care Advance Access published April 22, 2009

gap between what professionals do for patients with chronicdiseases (e.g. COPD) and what should be done [8]. Thisraises questions about professional commitment in changingchronic illness care. There are currently no research reports,however, examining professionals’ roles in implementingdisease management within primary care.

In general, variations in degree of implementation ofchanges can be attributed to characteristics of the pro-fessionals, but also to the organizational context [9, 10]. Theaim of this exploratory study is to investigate to what extentprimary care professionals are able to change their processesfor delivering care to COPD patients, and what professionaland organizational factors are associated with the degree ofprocess implementation.

Theoretical framework

The framework is based on theoretical approaches byCretin et al. [9] and Lin et al. [7]. Both papers argue that amultilevel approach is needed to improve quality; they focuson professional level as well as organizational context. Thisstudy combines the approaches by relating professional andorganizational factors to changes in processes of care(Fig. 1). At professional level, professional commitment isapproached in terms of motivation, using the expectancytheory [11, 12]. This theory acknowledges the multifacetednature of professional commitment by distinguishing valence,instrumentality and expectancy. Valence is the attractivenessthat professionals assign to the outcomes associated withsuccessful implementation of disease management. Theseoutcomes induce both intrinsic and extrinsic rewards, suchas improvement in patient health and satisfaction or higherprofessional self-esteem. Instrumentality refers to the beliefthat disease management implementation will lead to thesetargeted outcomes. Expectancy concerns the associationbetween effort and success in disease managementimplementation. Thus, the product of an individual’s assess-ment of valence, instrumentality and expectancy is the pro-fessional commitment towards implementing diseasemanagement [7, 12].

Culture, organizational commitment to quality improve-ment and climate are considered to be important conditionsin the organizational context. They provide information onthe setting and contingencies that professionals are con-fronted with in their work environment [13]. Culture con-cerns the norms, values, beliefs and behaviours of anorganization, reflecting ‘how we do things around here’. Thecompeting values framework distinguishes four types ofculture: group culture (teamwork and participation), devel-opmental culture (risk-taking, innovation and change), hier-archical culture (rules, regulations and bureaucracy) andrational culture (efficiency, goal attainment and achievement)[14, 15]. Previous research on chronic care improvementshowed that having a group culture is related to higher com-mitment from professionals [16]. The core principles ofdisease management emphasize change and teamworkefforts; hence, group culture may be a facilitator for chroniccare improvement. A higher degree of the practice group’scommitment to quality improvement is expected to posi-tively influence professional commitment as well, sincequality activities are hypothesized to support implementationof disease management. Climate refers to an individual’sperception of the environmental and organizational contin-gencies between individual behaviours related to COPDmanagement and anticipated collegial responses [15].Professionals are hypothesized to be more committed toimplementing COPD management when they perceive asupportive climate [7]. A group culture, a supportive climateand commitment to quality tend to create a positive work-place with dedicated professionals working together effec-tively [17]. This supports the development andimplementation of system changes that improve processesand, ultimately, patient outcomes.

Previous research [9, 18] suggests that it is the interplaybetween professional level factors and the organizationalcontext that explains the success or failure of the implemen-tation of disease management programmes. This studyexplores associations between professional commitment,organizational context and perceived degree of implemen-tation of changes within current practice groups of COPD(Fig. 1).

Figure 1 Theoretical model on professional commitment to changing chronic illness care.

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Methods

Setting and design

This study evaluates professionals’ commitment within threeregional pilots of COPD management programmes in theNetherlands. The pilot studies were supported by Partners inCare Solutions for COPD, a national programme that aimsto optimize COPD care by supporting the implementationof disease management. The programmes were carried outin 21 general practices in central Netherlands: the ‘GelderseVallei’ region, Doetinchem and Nijmegen. The practicescoordinated with the regional hospital(s) and were supportedby their own practice nurses or practice nurses of a regionalhome care organization.

The COPD management programme consisted of patienteducation, protocolized assessment and treatment of COPD,and coordination of care. Practice nurses systematically edu-cated patients on smoking behaviour, medication usage,nutrition and physical activity so as to increase their under-standing of COPD and self-management skills. Next to that,professionals were educated on the guidelines and pro-gramme. These interventions were supported by organiz-ational interventions. A multidisciplinary team (generalpractitioner, practice nurse and a lung specialist) coordinateddiagnostic procedures, treatment and ongoing patient man-agement. Team members’ tasks and responsibilities weredescribed in a guideline-based protocol. Practice nurses per-formed lung function tests, assessed patients’ conditions,provided disease-related education and advice, coordinatedcare and organized follow-up meetings. They acted in con-junction with the general practitioner who consulted thespecialist when needed. Figure 2 shows the specific character-istics of these programmes and specific differences betweenthe regions. It shows that the programmes are rather similar.

An exploratory study was performed as part of a largerevaluation study on COPD management programmes in theNetherlands. Data were collected by means of postal ques-tionnaires at baseline and 1 year after intervention. Both theresearcher and the programme manager invited the pro-fessionals involved in these programmes to complete thequestionnaire. The characteristics and psychometric proper-ties of the measures are described in Table 1.

Questionnaire

Professionals completed a questionnaire based on theimproving chronic illness care questionnaire [7]. Areascovered were (i) general professional characteristics,(ii) COPD disease management implementation and(iii) factors associated with changing chronic COPD care.The first part related to background characteristics, such asduration of professional activity. Second, the assessingchronic illness care survey [19] aimed to determine the per-ceived degree of actual implementation of the programme.Only the elements reflecting the interventions withinthe disease management programme were included: self-management support (patient-related intervention), decision

support (professional-directed intervention), delivery systemdesign and clinical information systems (both evaluatingimplementation of the organizational intervention) (Fig. 2).The four to six items per element were rated on a 0–11response scale, with higher scores indicating more completeimplementation. Mean scores for each element wereobtained. To validate self-reports by professionals, we com-pared changes in assessing chronic illness care elements toavailable data on structural changes in care practices and toavailable process measures, namely application of patienteducation for changes in self-management support, provisionof inhalation instruction and application of spirometry forchanges in decision support and regularity of follow-up forchanges in delivery system design. The process measureswere expressed as percentages of patients within practiceswho received a specific intervention.

The third part of the questionnaire measured professionalcommitment in implementing COPD management (pro-fessional level: valence, instrumentality and expectancy) andidentified relevant contextual factors (organizational level:culture, commitment and climate). Valence is measured on a9-item scale; professionals are asked to report the importanceof each of the described outcomes, for example, improvingcontinuity of care. Response categories range from 1 (notimportant) to 5 (extremely important). Instrumentality ismade up of nine items; response categories range from 1(strongly disagree) to 7 (strongly agree). Expectancy is asingle item to be rated from 1 (strongly disagree) to 7(strongly agree) in response to a statement on the associationbetween effort and success in disease managementimplementation. Consistent with Vroom’s conceptualizationof the expectancy framework [12], these scales add up toone professional commitment score.

Culture was assessed using the competing values frame-work [13], which asks respondents to distribute 100 pointsacross series of four statements on the culture of their prac-tice group. These statements reflect the four culture types.Commitment to quality improvement is measured by anoverall average score on quality improvement questions bythe European foundation for quality management scaleadapted for primary care [13, 20]. Response categories rangefrom 1 (strongly disagree) to 5 (strongly agree). The scalecovers four subjects: policy and strategy, quality development,employee involvement and customer satisfaction. Examplesof items are: ‘the practice group uses data from patients toimprove services’ and ‘professionals are recognized forimproving quality’. Climate is measured as the average offour questions assessing expected collegial responses to initi-ating behaviours and performing tasks related to COPDmanagement [7]. Response categories range from 1 (admoni-tion or disapproval) to 4 (reward or approval).

Statistical analyses

For all study variables, comparisons were made between base-line (T0) and post-intervention (T1) data using paired-sampled t-tests and Wilcoxon signed rank tests (one sided;a ¼ 0.05) where appropriate. Process changes in assessing

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Figure 2 Disease management interventions in the disease management programmes.

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Table 1 Descriptive statistics of theoretical constructs and instruments per variable

Construct Variable(s) Instrument No. of items Range Cronbach’s a T0, mean (SD) T1, mean (SD) Change (95% CI) P-value

Organizationalfactors

Culture CVF 20 0–100Group 40.8 (17.0) 40.6 (18.6) 20.3 (23.7 to 3.1) 0.88Developmental 27.7 (14.3) 26.2 (12.2) 21.4 (25.6 to 2.8) 0.49Hierarchical 16.3 (9.8) 19.0 (11.1) 2.7 (20.3 to 5.6) 0.07Rational 15.1 (10.9) 14.0 ( 9.7) 21.1 (24.1 to 1.8) 0.44

QI commitment EFQM 3.8 (0.5) 3.8 (0.6) 0.0 (20.2 to 0.2) 0.89Policy andstrategy

5 1–5 0.69 3.9 (0.6) 4.0 (0.7) 0.1 (20.2 to 0.3) 0.77

Qualitydevelopment

5 1–5 0.78 3.8 (0.6) 4.0 (0.6) 0.1 (20.1 to 0.3) 0.23

Employeeinvolvement

4 1–5 0.78 3.9 (0.6) 3.8 (0.7) 20.1 (20.4 to 0.1) 0.23

Customersatisfaction

5 1–5 0.76 3.4 (0.6) 3.4 (0.6) 0.0 (20.2 to 0.2) 0.97

Climate ICIC 4 1–4 0.48 3.0 (0.3) 3.5 (0.5) 0.5 (0.4 to 0.7) ,0.001Professionalcommitment

Professionalcommitment

124.8 (28.0) 135.7 (33.8) 10.9 (1.6 to 20.3) 0.02

Valence ICIC 9 1–5 0.87 3.6 (0.5) 3.8 (0.5) 0.2 (0.1 to 0.3) 0.009Instrumentality ICIC 9 1–7 0.78 5.7 (0.5) 5.8 (0.5) 0.1 (0.0 to 0.2) 0.16Expectancy ICIC 1 1–7 6.1 (0.8) 6.2 (0.8) 0.1 (20.2 to 0.4) 0.58

Changes incare processes

Self-managementsupport

ACIC 4 0–11 0.94 4.8 (2.5) 7.2 (1.7) 2.4 (1.7 to 3.1) ,0.001

Decision support ACIC 4 0–11 0.85 5.8 (1.9) 7.5 (1.3) 1.7 (1.1 to 2.3) ,0.001Delivery systemdesign

ACIC 6 0–11 0.94 4.8 (2.3) 7.7 (1.3) 3.0 (2.3 to 3.6) ,0.001

Clinicalinformationsystems

ACIC 5 0–11 0.91 4.5 (2.3) 6.7 (1.6) 2.3 (1.7 to 2.9) ,0.001

QI, quality improvement; CVF, competing values framework; EFQM, European foundation for quality management; ICIC, improving chronic illness care and ACIC, assessing chronic illnesscare.

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chronic illness care were validated by comparing them to theprocess measures using Pearson’s correlation coefficients.Differences between groups determined by professionalcharacteristics were explored with Mann–Whitney U tests. Todetermine whether the theoretical model propositions areconsistent with the data, regression analyses were applied intwo steps. The associations between organizational context,professional commitment and degree of process changes wereexplored using professional commitment as a mediator vari-able (Fig. 1) [21]. Baseline as well as change scores wereentered into the model to account for the individual baselinelevels and to control for regression to the mean effects [22].Data were analysed using SPSS 13 for Windows. A prior sig-nificance level of 0.05 was used for all statistical tests.

Results

Response and characteristics

The eligible study population consisted of 60 professionals.Initial responses were received from 54 professionals; as 2were lost to follow-up, the final response rate was 87%.Professional characteristics at baseline are presented inTable 2. We explored the differences between general prac-titioners and practice nurses. Overall, the latter tended to scoremore positively; differing significantly on instrumentality andthe implementation of information systems. Furthermore, pro-fessionals with specific COPD education had significantlyhigher scores on COPD management implementation, exceptfor decision support. After the implementation of the diseasemanagement intervention, these differences dissipated.

Professional commitment

At baseline, attractiveness assigned to the outcomes associ-ated with successful implementation of COPD management(valence) was rated a mean 3.57 (+0.44) on a 1–5 scale.This indicates that professionals attach importance to theseoutcomes. The statement that implementation of diseasemanagement leads to the targeted outcomes was rated amean of 5.69 (+0.51) (1–7 scale), denoting that pro-fessionals believe that they can successfully implementCOPD management. Expectancy was rated a mean of 6.10(+0.75) (1–7 scale), which implies that disease managementis seen as an effective tool in improving outcomes. Thesemeasures add up to an overall professional commitmentscore of 124.8 (+28.0). Comparing baseline and post-intervention scores showed that professional commitment(P ¼ 0.02) and valence (P ¼ 0.009) had improved signifi-cantly after intervention (Table 1).

Organizational context

At baseline, most professionals (62%) indicated thattheir practice is best characterized by a group culture; 23%indicated their practice culture as developmental. A rationalculture and a hierarchical culture each were perceived by

only 8%. Questions related to commitment to qualityimprovement were rated with a mean of 3.79 (+0.47) on a1–5 scale; scores for the four items ranged from 3.40(+0.57) to 3.91 (+0.57). These scores indicate a relativelyhigh commitment to quality, involving staff members andsupported by strategy. With regard to climate, professionalsgave a rating of 2.96 (+0.29) on a 1–4 scale for the expec-tation of a somewhat positive collegial response when theywould initiate behaviours and perform tasks related toCOPD management. After the intervention, the climate hadimproved significantly (P , 0.001). No significant changeswere found on culture and commitment to quality improve-ment (Table 1).

Programme implementation

Table 1 also summarizes the extent to which the pro-fessionals felt that the disease management programme wasactually implemented (process changes). Overall, subscalescores at baseline ranged from 4.45 (information systems) to5.80 (decision support). This indicates that basic support forCOPD management was present, for example, facilitatingaccess to evidence-based guidelines or providing educationalmaterials to patients [19]. Scores for all elements—self-management support, decision support, delivery system

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Table 2 Professional characteristics at baseline

Characteristic % (n)

SexMale 50 (27)Female 50 (27)

ProfessionGeneralpractitioner

61 (33)

Practice nurse 31 (17)Practiceassistant

4 (2)

Physiotherapist 4 (2)Years in practice

0–1 year 6 (3)1–5 years 26 (14)5–10 years 19 (10)Longer than10 years

50 (27)

Specific COPD educationYes 63 (34)No 37 (20)

Number of hours a week working with COPD patients,8 h 68 (35)8–15 h 12 (6)16–22 h 12 (6).22 h 8 (4)

Participating in regional multidisciplinary COPD meetingsYes 64 (35)No 36 (19)

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design and clinical information systems—improved signifi-cantly after intervention, with delivery system design to thehighest degree. Changes in self-reported, self-managementsupport and actual application of patient education in prac-tice correlated significantly (r ¼ 0.38, P , 0.01). Changes indecision support correlated significantly with provision ofinhalation instruction (r ¼ 0.52, P , 0.01) and changes indelivery system design correlated significantly with the pro-portions of patients regularly followed up (r ¼ 0.42, P ,

0.01). In addition, the process measures showed that allpatients underwent spirometry as indicated by guidelines,validating reported improvements in decision support.

Professional commitment to changing chronicillness care

Table 3 presents zero-order correlations between all variablesof the model (Fig. 1). It shows that climate baseline (r ¼0.24, P , 0.05) and climate change scores (r ¼ 0.31, P ,

0.05) correlate significantly with professional commitment atbaseline. Changes in commitment to quality improvementand changes in professional commitment correlate marginallyand significantly with each other (r ¼ 0.23, P , 0.10). Nosignificant correlations were found between group cultureand professional commitment. Furthermore, (marginal) sig-nificant correlations are found between organizational orprofessional factors and process changes, except for decisionsupport.

Table 4 shows the results of the regression analyses thatexplored whether organizational context and professionalcommitment could be predictors of changes in processes ofcare. In order to compare the magnitude of the effects ofvarious independent variables, we presented the standardizedregression coefficients from the models. In the final model,group culture at baseline appeared to be a significant predic-tor of process changes in self-management support, deliverysystem design and disease management (total score), withstandardized regression coefficients of 0.38, 0.52 and 0.40,respectively. In the multiple regression models for processchanges in delivery system design, clinical informationsystems and disease management, (marginally) significanteffects of professional commitment at baseline were found inthe final model as well, with standardized regression coeffi-cients of 0.34, 0.38 and 0.34, respectively. Total explainedvariance after adjustment was small; except for the deliverysystem design (22%). Professional commitment was notidentified as a mediator of organizational factors in influen-cing process changes.

Discussion

The aim of this study was to explore factors that contributeto success or failure of the implementation of disease man-agement programmes. COPD management was effective; allprocesses changed significantly. Furthermore, these explora-tory results provided some support for the theoretically pro-posed associations between organizational, professional

factors and the degree of process changes. The presence of agroup culture and professional commitment were indeedassociated with positive changes in processes of care.Moreover, these factors were found to be significant predic-tors of process changes to a moderate degree. The significanteffect of group culture on process changes can be explainedby a more autonomous way of working within a groupculture; fewer rules and agreements enhance implementationof improvements. Health care cultures that emphasize groupaffiliation, teamwork and coordination have been associatedwith more complete implementation of quality improvement[17, 23]. Accordingly, professional commitment was associ-ated with more complete disease management implemen-tation. As this association was not confirmed for all processchanges, it would seem that the professionals’ commitmentto change is determined by particular characteristics of theinterventions (self-management, guidelines, information tech-nology), which may promote or hamper their actual adop-tion. This is widely discussed in various theories on involvingprofessionals in implementation of innovations [24].

Previous research identified a number of barriers to pro-fessionals’ commitment in changing chronic illness care [25].The present study finds some evidence that a supportiveclimate is associated with professional commitment, implyingthat peer support is an important motivator of professionalcommitment. In contrast to culture, climate is an individualperception of the day-to-day practice group environment. Itis therefore interesting that a supportive climate stimulatesprofessionals to engage in improving chronic illness care.The finding that change in commitment to quality improve-ment is associated with change in professional commitmentconfirms our initial hypothesis; quality activities within apractice group do support implementation of disease man-agement. Various associations were found between organiz-ational factors and professional commitment on the onehand and changes in processes of care on the other, provid-ing support for our theoretical model. No associations werefound between professional and organizational factors andchanges in decision support, probably due to only smallchanges in this parameter. A high baseline score left littleroom for improvement. General practices apparently arerather used to working with guidelines, as a major tool formaking clinical decisions and improving patient care [26].

One of the critical factors for better chronic disease man-agement is the effective use of specialized practice nurses[27]. This study shows that practice nurses strongly believethat one can really achieve the desired change in general prac-tice, an attitude that may act as a catalyst to adapting diseasemanagement in primary care. Previous research showed thatlack of outcome expectancy was a possible barrier in imple-menting the changes in health care. There was great vari-ation, however, among patient groups, with positive results inthe case of alcohol abuse prevention but not for clinicalbreast screening [28]. The present study shows that diseasemanagement is seen as an effective tool in improvingoutcomes in COPD care, as can be derived from high scoreson expectancy and valence. Furthermore, significantlyimproved professional commitment and valence suggest that

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Table 3 Zero-order correlations between independent and dependent variables (n ¼ 52)

1. GroupcultureT0

2. QIcommitmentT0

3.ClimateT0

4. DGroupculture

5. D QIcommitment

6. DClimate

7.ProfessionalcommitmentT0

8. DProfessionalcommitment

9. DSelf-managementsupport

10. DDecisionsupport

11. DDeliverysystemdesign

12. DClinicalinformationsystems

2. QIcommitment T0

20.17

3. Climate T0 0.01 0.154. D Groupculture

20.20*** 20.07 0.26**

5. D QIcommitment

20.02 20.48* 20.03 0.14

6. D Climate 0.22*** 20.07 20.25** 20.17 0.087. Professionalcommitment T0

20.06 0.07 0.24** 20.18 20.04 0.31**

8. D Professionalcommitment

20.00 0.18 20.14 0.02 0.23*** 20.04 20.41

9. DSelf-managementsupport

0.35* 20.10 0.22*** 0.05 0.04 0.07 0.18*** 20.03

10. D Decisionsupport

0.21*** 0.04 0.22*** 20.12 0.14 0.03 0.13 0.19*** 0.43*

11. D Deliverysystem design

0.46* 20.09 0.18 0.07 0.07 0.06 0.13 0.14 0.79* 0.66*

12. D Clinicalinformationsystems

0.21*** 0.08 0.18 20.17 20.02 0.11 0.35** 20.02 0.72* 0.57* 0.77*

13. D Diseasemanagement

0.36* 20.02 0.23*** 20.04 0.06 0.06 0.22*** 0.08 0.87* 0.76* 0.94* 0.89*

Correlations are significant at the *0.01, **0.05 and ***0.10 levels (one tailed).

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professionals’ and their exposure to disease managementprogrammes may positively influence the behavioural inten-tion of professionals to implement disease management,which is confirmed by previous findings [29].

To date, most health care improvements have been targetedat factors related to individual professionals [30]. Still, achiev-ing changes in health care typically will require interplaybetween a range of factors at different levels, i.e. professionallevel, organizational context and the economic and politicalcontext [24]. To determine whether and to what extentchange is achieved, we will need information on all levels [9].This study provides a first empirical test of a theoreticalmodel on professional and organizational aspects importantin changing chronic illness care. By combining two models,this multilevel approach was effectuated. Yet, more research isneeded, including research on internal and external incentives,such as financial support or quality targets.

Findings of this study must be interpreted in the light ofseveral limitations. First, this study was an exploratory analy-sis as part of a research project on COPD disease manage-ment programmes. Consequently, the sample of the studywas small, leaving limited predictive power of organizationaland professional factors in process changes. Furthermore,mass significance in the regression analyses may have led totoo positive results. However, we explicitly tested associationsderived from a theoretical model. To avoid type one errors,we set the significance level at 0.05 (one tailed). Second, self-reported instruments were used. The assessing chronicillness care measures professionals’ perceptions; these per-ceptions may have been influenced by the professionals’expectations in addition to the actual implementation.However, professionals’ perceptions were validated by avail-able process measures. Even though these process measuresonly reflect part of the change in practice, we foundassociations between these measures and reported changesin related assessing chronic illness care domains: self-management support, decision support and delivery systemdesign. Whereas assessing chronic illness care is a multidi-mensional survey, process measures only measure fragmentsof changes. In addition, structural changes within the pro-grammes were also apparent, such as COPD consulting

hours, specialized nurses and a COPD registry within prac-tices, which supports the changes reported by professionalsby pointing to actual implementation of the programme.Third, this study concerned pilot programmes. This mayhave biased the results, since professionals participating inpilot programmes may be assumed to have a fair degree ofcommitment right from the start. Yet, despite high baselinescores significant improvements in these pilots were found,which suggests improvement possibilities for practices whichare less far ahead in disease management implementation.Hence, large-scale follow-up research is needed.

In conclusion, the present exploratory study showed thatprofessionals significantly changed their systems for deliver-ing care to COPD patients. Organizational context and pro-fessional factors proved to be instrumental to these changes.Group culture and professional commitment are importantfacilitators for implementation of COPD management inprimary care.

Funding

The research project was supported by an unrestricted grantfrom PICASSO for COPD, an initiative of Pfizer BV andBoehringer Ingelheim BV in cooperation with research insti-tute Caphri (Care and Public Health Research Institute) ofMaastricht University.

References

1. WHO. Chronic Diseases and their Common Risk Factors. Geneva:World Health Organization. http://www.who.int/chp/chronic_disease_report/media/Factsheet1.pdf (27 March 2009, date lastaccessed).

2. Bellamy D, Smith J. Role of primary care in early diagnosis andeffective management of COPD. Int J Clin Pract2007;61:1380–9.

3. Ellrodt G, Cook D, Lee J et al. Evidence-based disease manage-ment. J Am Med Assoc 1997;278:1687–92.

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Table 4 Determinants of process changes from hierarchical regression analyses (standardized regression coefficients)

Variables Self-managementsupport

Decisionsupport

Deliverysystem design

Clinical informationsystems

Diseasemanagement

Group culture T0 0.38** 0.21 0.52* 0.22 0.40**QI commitment T0 20.11 0.03 20.10 0.03 20.05Climate T0 0.15 0.23 0.08 0.12 0.16D Group culture 0.12 20.14 0.19 20.09 0.03D QI commitment 20.03 0.13 20.05 0.00 0.01D Climate 20.03 20.04 20.10 20.03 20.07Professional commitment T0 0.26 0.19 0.34** 0.38** 0.34***D Professional commitment 0.12 0.27 0.31*** 0.15 0.25Adjusted R2 0.07 0.04 0.22 0.05 0.12

*P , 0.01; **P , 0.05 and ***P , 0.10 (one tailed) pairwise.

Professional commitment to changing chronic illness care

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Accepted for publication 30 March 2009

Lemmens et al.

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