Relationship Between the Chronic Care Model and Diabetes Outcomes

1
Relationship Between the Chronic Care Model and
Diabetes Outcomes

• Laurie Hurowitz, PhD,
• Benjamin Littenberg, MD, and
• Charles D. MacLean, MDCM
• General Internal Medicine, College of Medicine
• AcademyHealth, Boston, MA, June 28, 2005

2
Context Chronic Illness Care

• Current health care services are designed to
  deliver acute care
• Need to redesign health care to deliver
• more effective preventive services
• more effective services to those with one or more
  chronic illnesses

3
The Chronic Care Model (CCM)
Community Resources Policies
Health System Organization
Organization of Care
Decision Support
Clinical Information Systems
Self-Management Support
4
Current Research CCM Outcomes

• Most research has focused on elements of the CCM
  and outcomes, and not the model as a whole.
• Clinical Tool Assessment of Chronic Illness Care
  pre/post measure, sensitive to organizational
  change.

5
Research Question

• What is the relationship between primary care
  practice organization across all components of
  the Chronic Care Model and glycemic control for
  patients with diabetes?

6
Methods

• Design - Cross-sectional, observational study
• Subjects - Adults diagnosed with diabetes in care
  in primary care practices in a rural VT, NH, and
  NY.
• 2 measures

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Predictor Measure

• The Assessment of Diabetes Care, adapted from
• the Assessment of Chronic Illness Care version
  3.5
• (organizational change - organizational status)
• 33 prompts/stems
• 12-point response scale descriptors provided
• Subscale scores (0-11) overall score is average
  (0-11)
• Practice average average across all
  practitioners
• Higher scores are associated with greater
  conformance with the CCM.

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Sample Item Subscale Overall System of Health
Care
Overall Goals for Diabetes Care (circle one) 0
1 2 3 4 5 6
7 8 9 10 11
Do not exist. Exist but are not
Are measurable Are measurable, reviewed
actively reviewed.
and reviewed. routinely, and incorporated

into
plans for improvement.
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Outcome Measure

• Glycosylated hemoglobin, as measured by
• the A1C assay (A1C)
• Source
• adult patients diagnosed with diabetes
• Practice average - baseline measure from the
  Vermont Diabetes Information System (VDIS)
• For patients with diabetes, lower A1Cs are
• associated with better clinical outcomes.
• Even small decreases are related to
• improving the burden of diabetes.

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Results
Practice Characteristics N30
of Practices w/ one PCP completing ADC ( VDIS) 30 (48)
of PCPs completing the ADC Survey ( of total in VDIS) 50 (40)
Number of PCPs/Practice Completing Survey 1 to 5
Average Number of Patients with Diabetes/Practice (range) 98 (12-275)
Average ADC Score (range) 4.6 basic (2.7 limited to 6.9 reasonably good)
At baseline, VDIS had 62 practices with 124
PCPs.
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Results (continued)
Patient Characteristics (n3,819)
Average Patient Age (yrs) (range among practices) 61.2 (52-73)
Male 51
Average A1C (mean practice range) 7.2 (6.4-8.2)
This subset is 62 of the 6,124 patients
participating in VDIS at baseline. This subset
did not differ significantly from the group as a
whole, by age or by gender.
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Conformance with the CCM Diabetes
OutcomesPractice Detail (N30 n3,819)
13
Conformance with the CCM Diabetes
OutcomesPractice Detail (N30 n3,819)
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Conformance with the CCM Diabetes
OutcomesLinear Regression (N30 n3,819)
Regression results - Adjusting for age, the
relationship between the average ADC score and
glycemic control had a regression coefficient of
-0.11 (p0.029 95 CI -0.21 to -0.01).
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Conclusions

• Patients who receive care in practices that
  conform to the Chronic Care Model have better
  glycemic control.
• This study lends support to the overall validity
  of the Chronic Care Model and its relationship to
  better outcomes for patients with diabetes.

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References

• Bodenheimer T, Wagner EH, Grumbach K. Improving
  primary care for patients with chronic illness.
  JAMA 2002, Oct 9 288(14)1775-9 and Part 2.
  JAMA 2992 Oct 16288(15)1909-14.
• Bonomi AE, Wagner EH, Glasgow R, Vonkroff M.
  Assessment of chronic illness care a practical
  tool for quality improvement. Health Services
  Research. 2002 37(3)791-820.
• MacLean CD, Littenberg B, Gagnon M, Reardon M,
  Turner PD and Jordan C. The Vermont Diabetes
  Information System (VDIS) study design and
  subject recruitment for a cluster randomized
  trial of a decision support system in a regional
  sample of primary care practices. Clinical
  Trials. 20041532-544.
• Shojania KG, Ranji SR, Shaw LK, Charo LN, Lai JC,
  Rushakoff RJ, McDonald KM, Owens DK. Diabetes
  mellitus care. Closing the quality gap a
  critical analysis of quality improvement
  strategies, Vol 2. Technical review 9, AHRQ Pub
  no. 04-0051-2. Rockville, MD. Sept 2004.
• The Chronic Care Model and Clinical Tools.
  www.improvingchroniccare.org.
• The Diabetes Control and Complications Trial
  Research Group. The effect of intensive
  treatment of diabetes on the development and
  progression of long-term complications in
  insulin-dependent diabetes mellitus. N Engl J
  Med. 1993329977-986.
• Wagner EH, Glasgow RE, Davis C, Bonomi AE,
  Provost L, McCulloch D, Carver P, Sixta C.
  Quality improvement in chronic illness care a
  collaborative approach. Jt Comm J Qual Improv
  2001 Feb 27(2)63-80.

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How to Contact Us Study Support

• For further information, please contact
• Laurie.Hurowitz_at_uvm.edu
• This study was supported by the National
  Institute of Diabetes and Digestive and Kidney
  Disease (K24DK068380 and R01DK61167)