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
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
The Chronic Care Model (CCM)
Community
Resources
& Policies
Organization
of Care
Health
System
Organization
Delivery System Design
Decision Support
Clinical Information Systems
Self-Management Support
Productive Interactions
Informed, Activated
Patient
Prepared, Proactive
Practice Team
Functional and Clinical Outcomes
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.
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?
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
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.
Sample Item
Subscale: Overall System of Health Care
Overall Goals for Diabetes Care (circle one) :
0
1
2
Do not exist.
3
4
5
6
7
8
9
10
11
Exist but are not Are measurable Are measurable, reviewed
actively reviewed. and reviewed.
routinely, and incorporated
into plans for improvement.
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.
Results
Practice Characteristics
N=30
# 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.
Results (continued)
Patient Characteristics*
(n=3,819)
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.
Conformance with the CCM
& Diabetes Outcomes
Practice Detail (N=30; n=3,819)
9
8
Average ADC
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
30 Primary Care Practices
Conformance with the CCM
& Diabetes Outcomes
Practice Detail (N=30; n=3,819)
Average A1C
9
8
7
6
Average ADC
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
30 Primary Care Practices
21
22
23
24
25
26
27
28
29
30
Conformance with the CCM
& Diabetes Outcomes
Linear Regression (N=30; n=3,819)
9
Practice Average A1C
8
7
6
Regression results - Adjusting for age, the
relationship between the average ADC score and
glycemic control had a regression coefficient of
-0.11 (p=0.029; 95% CI -0.21 to -0.01).
5
4
3
2
1
0
0
1
2
3
4
5
Practice Average ADC Score
6
7
8
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.
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 16:288(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. 2004;1:532-544.
•
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. 1993;329:977-986.
•
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.
How to Contact Us
& Study Support
For further information, please contact:
Laurie.Hurowitz@uvm.edu
This study was supported by the National Institute
of Diabetes and Digestive and Kidney Disease
(K24DK068380 and R01DK61167)