The Effect of Primary Health Care Orientation on Chronic Illness Care Management

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The Effect of Primary Health Care Orientation on
Chronic Illness Care Management

• Julie Schmittdiel, Ph.D.,
• Stephen M. Shortell, Ph.D.,
• Thomas Rundall, Ph.D.
• AcademyHealth Annual Research Meeting
• June 7, 2004
• (Funded by Robert Wood Johnson Foundation Award
  038690)

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Introduction

• Chronic illness places huge burden on U.S. health
  care system 125 million patients generate 75 of
  costs
• Institute of Medicine(2001) reports a quality
  chasm in chronic illness care provided to
  patients
• Improving chronic illness care delivery in the
  primary care setting has great potential for
  helping bridge chasm (Bodenheimer, Wagner and
  Grumbach 2002)

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Introduction, cont.

• Focus on acute problems and episodic care makes
  current primary care system ill-equipped to deal
  with chronic illness
• A focus on comprehensive care and overall patient
  health (primary health care) could create an
  ideal environment for improved chronic illness
  care
• Lack of empirical work examining whether greater
  primary health care orientation relates to
  improved chronic illness care processes

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Research Question

• Does a physician organizations primary health
  care orientation affect its delivery of chronic
  illness care?

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The Chronic Care Model (Wagner et al)

• Community Linkages mobilize community resources
  for chronic illness patients
• Health System Organization leadership commitment
  to chronic illness care and its outcome
• Patient Self-Management Support encourage
  lifestyle changes and developing of illness
  management skills
• Delivery System Design offer team-based care and
  patient follow-up
• Decision Support for Providers train providers
  in evidence-based guidelines and give access to
  specialist expertise
• Clinical Information Systems electronic medical
  data systems use for provider feedback,
  reminders, and care planning
• See www.improvingchroniccare.org for more details

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Primary Health Care (Starfield 1992)

• First Contact primary care providers provide
  window to use of specialists
• Continuity primary care provider/patient
  relationship is long-term and consistent
• Comprehensiveness primary care provides wide
  range of services across settings
• Coordination primary care coordinates with care
  from other sources
• Accountability primary care providers feel
  ultimately responsible for overall patient health

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Research Hypothesis

• Similarities across concepts suggest that
  organizations practicing primary health care may
  be more committed to the Chronic Care Model.
• Research Hypothesis Physician organizations
  with a high degree of overall primary health care
  orientation will have a higher degree of Chronic
  Care Model implementation.

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Data Source

• National Study of Physician Organizations (NSPO)
• Cross-sectional survey of all U.S. physician
  organizations with 20 or more MDs
• Data collected from Sept. 2000-Sept. 2001
• Assessed chronic illness care processes, IT,
  external incentives, organizational/financial
  characteristics
• 70 response rate n64 treating no chronic
  illness deleted
• Result of n1,040 organizations for analysis

further information and survey instrument
available at http//nspo.berkeley.edu
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Dependent Variable Chronic Care Model Index
11-point Chronic Care Model Index Mean(SD) 4.6 (2.9)
Agreements with Comm. Services Agencies 20.2
Referrals to Comm. Services Agencies 32.4
Assess Self-Management Needs 44.8
Self-Management Programs 56.6
Integrate Guidelines into Care 51.4
Integrate Specialists into Care 62.2
Utilize Planned Visits 56.0
Multiple Providers Seen in one Visit 36.3
Employ Case Managers 34.2
Written Feedback to MDs 36.6
Internet Comm. between MDs and Patients 25.9
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Independent Variables Primary Health Care
Orientation
Comprehensiveness Severe Chronic Illness Treated in Primary Care (range 0-4) mean (SD) .50 (.90)
Health Promotions Index (range 0-8) mean (SD) 2.5 (2.6)
Patient Education Index (range 0-4) mean (SD) 2.4 (1.5)
Coordination Use of Electronic Medical Record ( yes) 21.0
Use of Electronic Standardized Problem List ( yes) 17.7
Accountability Required Outside Reporting Index (range 0-4) mean (SD) 0.8 (1.4)
Patients PO Accepts Risk for Hospital Costs mean (SD) 22.0 (36.3)
Continuity Primary Care Physician Turnover Rate mean (SD) 5.7 (8.4)
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Method of Analysis Multivariate Linear
Regression

• Chronic Care Model Implementation Index
• f(Primary Health Care Orientation Variables,
• control variables)
• controlling for organization age, size, number
  of clinics, region, ownership, organization type,
  capitalization, county-level HMO penetration

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Analysis Results
Primary Health Care Orientation Variables B (S.E)
Comprehensiveness Severe Chronic Illness Treated in Primary Care .21 (.08)
Health Promotions Index .39(.03)
Patient Education Index .28 (.05)
Coordination Use of Electronic Medical Record .30 (.23)
Use of Electronic Standardized Problem List .51 (.23)
Accountability Required Outside Reporting Index .25 (.06)
Patients PO Accepts Risk for Hospital Costs .006(.002)
Continuity Primary Care Physician Turnover Rate -.01 (.009)
plt.001 plt.01 plt.05
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Summary of Results

• Strong support for Research Hypothesis
• Six of eight primary health care orientation
  variables significantly related to index of
  Chronic Care Model implementation
• Low levels of primary health care orientation in
  U.S. physician organizations
• Limited use of Chronic Care Model

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Health Policy Implications

• Empirical justification for improving chronic
  illness care within a primary health care setting
• Increasing primary health care orientation in
  physician organizations may improve chronic
  illness care processes
• By facilitating changes in the primary care
  system, stakeholders could benefit people with
  chronic illness

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Conclusion

• Chronic illness places a great burden on health
  care system
• This and other research demonstrates much room to
  improve quality of chronic illness care
• Creating a health care system with a greater
  primary health care orientation may help bridge
  quality chasm in chronic illness care