Outcome parameter | Instrument | Data source |
---|---|---|
Primary outcome | ||
All-cause hospitalizations | Data on admissions | IC |
Secondary outcomes | ||
Sociodemographic data | Single items from German standard questionnaire [44] | PQ |
Mortality | Patient chart | CRF/IC |
Quality of Life | EuroQol (EQ-5D) [45] | PQ |
 | Short Form 12 Health Questionnaire (SF 12) [46] | PQ |
Quality of Care | Patient Assessment of Chronic Illness Care (PACIC) [47] | PQ |
Depression | Patient Health Questionnaire (PHQ9) [48] | PQ |
Adherence | Medication Adherence Reporting Scale (MARS) [49] | PQ |
Physical Activity | The Rapid Assessment of Physical Activity (RAPA) [50] | PQ |
Smoking status | Self developed items | CRF |
Self-management CHF | European Selfcare Behaviour Scale (EHFScB) [51] | PQ |
Self-management COPD/DM | Self developed instrument | PQ |
Medication regimen | Pharmacy data | IC |
Healthcare costs | Data from hospital care, ambulatory care, nursing facilities, pharmacies, rehabilitation | IC |
Activities of daily living | ADL [52] IADL [53] | CRF |
Comorbidity | Cumulative Illness Rating Scale (CIRS) [54] | CRF |
Home visits/Practice visits | Self developed items | CRF |
CHF decompensation (CHF patients) | Self developed items | CRF |
COPD exacerbation (COPD patients) | Self developed items | CRF |
Hypoglycaemia (DM patients) | Self developed items | CRF |
Body mass index | Weight, Height | CRF |
Blood pressure (all patients) | Standardized Measurement in the practice | CRF |
Fasting glucose | Patient chart | CRF |
Hemoglobin-A1c | Patient chart | CRF |
Dyspnoea (CHF and COPD patients) | Current NYHA-classification (CHF patients) or current MRC Dyspnoe Score (COPD patients) [55] | CRF |
Forced expiratory volume (COPD patients) | Standardized Measurement in the practice | CRF |