Open Access Research article

Implementation of chronic illness care in German primary care practices – how do multimorbid older patients view routine care? A cross-sectional study using multilevel hierarchical modeling

Juliana J Petersen1*, Michael A Paulitsch1, Karola Mergenthal1, Jochen Gensichen2, Heike Hansen3, Siegfried Weyerer4, Steffi G Riedel-Heller5, Angela Fuchs6, Wolfgang Maier7, Horst Bickel8, Hans-Helmut König9, Birgitt Wiese10, Hendrik van den Bussche3, Martin Scherer3, Anne Dahlhaus1 and the MultiCare Study Group

Author Affiliations

1 Institute of General Practice, Goethe-University Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt/Main 60590, Germany

2 Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University, Bachstraße 18, Jena 07743, Germany

3 Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany

4 Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, J5, Mannheim 68159, Germany

5 Institute of Social Medicine, Occupational Health and Public Health, University of Leipzig, Philipp-Rosenthal-Straße 55, Leipzig 04103, Germany

6 Institute of General Practice, University of Düsseldorf, Moorenstraße 5, Düsseldorf 40225, Germany

7 Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, Bonn 53105, Germany

8 Department of Psychiatry, Technical University of Munich, Ismaninger Str. 22, München 81675, Germany

9 Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany

10 Working Group Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Hannover 30625, Germany

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BMC Health Services Research 2014, 14:336  doi:10.1186/1472-6963-14-336

Published: 7 August 2014



In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views.


This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice).


The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice.


This study shows that from the perspective of multimorbid patients receiving care in German primary care practices, the implementation of structured care and counseling could be improved, particularly by helping patients set specific goals, coordinating care, and arranging follow-up contacts. Studies evaluating chronic care should take into consideration that a patient’s assessment is associated not only with practice-level factors, but also with individual, patient-level factors.

Trial registration

Current Controlled Trials ISRCTN89818205.

Chronic disease; Multimorbidity; Chronic care model; Assessment of care; Patient-centred care