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Improving the continuity and coordination of ambulatory care through feedback and facilitated dialogue—a study protocol for a cluster-randomised trial to evaluate the ACD study (Accountable Care in Germany)

  • Sundmacher, Leonie1, 2
  • Flemming, Ronja1, 2
  • Leve, Verena3
  • Geiger, Isabel1, 2
  • Franke, Sebastian1, 2
  • Czihal, Thomas4
  • Krause, Clemens4
  • Wiese, Birgitt5
  • Meyer, Frank6
  • Brittner, Matthias6
  • Pollmanns, Johannes7
  • Martin, Johannes7
  • Brandenburg, Paul8
  • Schultz, Annemarie9
  • Brua, Emmanuelle9
  • Schneider, Udo10
  • Dortmann, Olga11
  • Rupprecht, Christoph11
  • Wilm, Stefan3
  • Schüttig, Wiebke1, 2
  • 1 Technical University of Munich,
  • 2 Ludwig-Maximilians-University Munich,
  • 3 Institute of General Practice of Heinrich-Heine University in Düsseldorf,
  • 4 Central Institute for SHI Physician Care in Germany (Zi), Salzufer 8, 10587 Berlin, Germany
  • 5 Hannover Medical School,
  • 6 Regional Association of Statutory Health Insurance Physicians Westphalia Lip, Robert-Schimrigk-Str. 4-6, 44141 Dortmund, Germany
  • 7 Regional Association of Statutory Health Insurance Physicians North Rhine, Tersteegenstraße 9, 40474 Düsseldorf, Germany
  • 8 Regional Association of Statutory Health Insurance Physicians Schleswig Holstein, Bismarckallee 1-6, 23795 Bad Segeberg, Germany
  • 9 Regional Association of Statutory Health Insurance Physicians Hamburg, Humboldtstraße 56, 22083 Hamburg, Germany
  • 10 Techniker Krankenkasse,
  • 11 AOK Health Insurance Rhineland/Hamburg, Kasernenstr. 61, 40213 Düsseldorf, Germany
Published Article
Springer (Biomed Central Ltd.)
Publication Date
Sep 15, 2021
DOI: 10.1186/s13063-021-05584-z
PMID: 34526088
PMCID: PMC8441947
PubMed Central
  • Study Protocol


Background Patients in Germany are free to seek care from any office-based physician and can always ask for multiple opinions on a diagnosis or treatment. The high density of physicians and the freedom to choose among them without referrals have led to a need for better coordination between the multiple health professionals treating any given patient. The objectives of this study are to (1) identify informal networks of physicians who treat the same patient population, (2) provide these physicians with feedback on their network and patients, using routine data and (3) give the physicians the opportunity to meet one another in facilitated network meetings. Methods The Accountable Care Deutschland (ACD) study is a prospective, non-blinded, cluster-randomised trial comprising a process and economic evaluation of informal networks among 12,525 GPs and office-based specialists and their 1.9 million patients. The units of allocation are the informal networks, which will be randomised either to the intervention (feedback and facilitated meetings) or control group (usual care). The informal networks will be generated by identifying connections between office-based physicians using complete datasets from the Regional Associations of Statutory Health Insurance (SHI) Physicians in Hamburg, Schleswig Holstein, North Rhine and Westphalia Lip, as well as data from three large statutory health insurers in Germany. The physicians will (a) receive feedback on selected indicators of their own treatment activity and that of the colleagues in their network and (b) will be invited to voluntary, facilitated network meetings by their Regional Association of SHI physicians. The primary outcome will be ambulatory-care-sensitive hospitalisations at baseline, at the end of the 2-year intervention period, and at six months and at 12 months after the end of the intervention period. Data will be analysed using the intention-to-treat principle. A pilot study preceded the ACD study. Discussion Cochrane reviews show that feedback can improve everyday medical practice by shedding light on previously unknown relationships. Providing physicians with information on how they are connected with their colleagues and what the outcomes are of care delivered within their informal networks can help them make these improvements, as well as strengthen their awareness of possible discontinuities in the care they provide. Trial registration German Clinical Trials Register DRKS00020884 . Registered on 25 March 2020—retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05584-z.

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