Organizational Approaches to
Improving Chronic Disease
Management
Bruce E. Landon, M.D., M.B.A.
Harvard Medical School
June 28, 2009
Agenda
• Background
– The Chronic Care Model
– Quality Improvement Collaboratives
• Evidence to date
• Challenges to research
• Policy implications
The Chronic Care Model
Source: Wagner et. Al, The McColl Institute
Collaborative Model for Improvement
Source: IHI
Anatomy of a Collaborative
Source: IHI
Studying the CCM and QI
Collaboratives
• CCM is often implemented via the QI
collaborative process…but all QI
collaboratives don’t involve implementing
the CCM
• Most participants self-selected
• Evaluations often use pre/post design
• Self-reported data
• Publication bias
Evidence from Controlled Trials
• HRSA Projects (EQHIV and the Health
Disparities Collaboratives)
• IHI/NICHQ
• RAND ICICE
The EQHIV Study
Quality Improvement Collaborative for HIV-infected patients
Source: Landon et al (2004). Ann Intern Med.
QI Intervention for Pediatric Asthma
Intervention
Measure
Control
Baseline
(n=294)
Post-period
(n=236)
Baseline
(n=337)
Post-period
(n=254)
Written asthma plan received in past 12 months (%)
53
54
37
41
Daily use of a controller medication in the past 4 weeks (%)
42
45
38
39
Daily use of an inhaled steroid medication in the past 4 weeks
(%)
17
17
15
17
Any asthma attacks in the past 12 months (%)
57
40
54
36
Mean limitation from strenuous exercise (scale of 1 to 5; 1-most
limited, 5-not limited)
4.1
4.3
4.2
4.4
Any asthma hospitalization in the past 12 months (%)
9
2
9
4
Any asthma ED visit in the past 12 months (%)
36
17
36
22
Based on results of QI collaborative involving 43 practices and 13,878 patients (randomized to control and intervention groups).
Source: Homer et al (2005). Arch Pediatr Adolesc Med.
The Health Disparities Collaborative
• Reduce disparities in health outcomes for
poor, minority, and other underserved
populations
• Application of the Chronic Care Model
using the IHI Breakthrough Series
Methodology
• Chronic diseases collaboratives involving
~1000 CHC sites since 1998
The Health Disparities Collaborative
Prospective Longitudinal Study of Diabetes Care in Community Health Centers, 1998-2002
Source: Chin et al (2007). Medical Care.
The Health Disparities Collaborative
Adjusted Composite Quality-of-Care Scores for Intervention and
Control Centers: Asthma, Diabetes and Hypertension
Measure
Intervention x
Internal Control
Intervention x
External Control
Overall
4.9***
4.5***
Prevention and Screening
6.2***
4.5**
Monitoring and Treatment
5.5***
5.9***
Outcomes
1.2
0.8
Asthma
Overall
6.9***
10.5***
Diabetes
Overall
7.5***
4.5**
Hypertension
Overall
2.1
-1.2
Condition
All Three Conditions
* p<.05, ** p<.01, *** p<.001
Source: Landon et al (2007). NEJM.
Improving Chronic Illness Care
Evaluation (ICICE)
•
•
•
•
Asthma
Depression
Diabetes
CHF
IHI Breakthrough Series Collaborative
for Chronic Heart Failure
Absolute Differences in Processes of Care for CHF, Intervention and Control Groups
Participating
Group
Indicator
Control Group
PostBTS
(%)
Change
from
Baseline
PostBTS
(%)
Change
from
Baseline
Difference
in Change
P Value
63
4
52
-9
0.089
93
13
87
-5
<0.0001
72
-1
67
-9
0.38
46
33
11
-4
<0.0001
59
-7
65
3
0.23
Diagnostic Indicators
LDL measured if CAD
Medication Indicators
ACEI for LVEF <40
Follow-up Indicators
Visit within 4 weeks after discharge
Counseling Indicators
Diet Counseling
Outcomes Indicators
BP <130/80 mmHg post MI or LVEF <40
Source: Asch et al (2005). Medical Care.
IHI Breakthrough Series Collaborative
for Chronic Heart Failure
Absolute Percent Changes in Intervention and Control Sites, by process indicator category
Source: Asch et al (2005). Medical Care.
IHI BTS for Diabetes Care
Adjusted Risk Change Difference and Number Needed to Treat
Adjusted Risk Change
Difference
95% Confidence
Interval
NNT
*
All patients
−2.1%
(−3.7%, −0.5%)
48
Upper tercile
UKPDS
−4.1%
(−7.1%, −1.0%)
24
Lower tercile
UKPDS
−1.0%
(−2.4%, 0.5%)
–
UKPDS 10-year risk
Results shown are the adjusted differences in the pre–post changes in 10year risk of myocardial infarction,
Vargas et. al., JGIM, 2007.
Literature Syntheses
• Coleman et al. 2009 (Health Affairs)
• Tsai et al. 2005 (AJMC)
Is the CCM Effective?
Coleman et al (2009) reviewed 82 empirical evaluation or observational studies of CCMbased interventions. CCM-based intervention was defined as:
(1) Intervention must operate within ambulatory care practices
(2) Intervention must require change in practices of clinical teams
(3) Intervention must be multi-component
(4) Intervention must integrate changes from most or all of the 6 CCM model areas
Research Question
Conclusions
Does the CCM improve delivery of care and
patient health outcomes?
Yes, in both national and international settings, CCM
implementation seems to improve both quality of care and
outcomes for patients with chronic illnesses.
Is a complex, multi-component model really
necessary?
Observational studies suggest highest performance is observed
in transformations that incorporate multiple CCM elements.
Results from studies that independently correlate CCM
elements with quality vary.
Is the CCM cost-effective?
More evidence is needed, but emerging evidence suggests the
CCM is cost-effective from a societal perspective; some
evidence suggests interventions may in some cases yield longterm savings.
Source: Coleman et al. (2009). Health Affairs.
Challenges to Research
•
•
•
•
•
Interventions evolve over time
The importance of context
Experiential learning
Multiple endpoints
Timing
Conclusions and Policy Implications
• Application of the CCM using the BTS
methodology holds promise…but change
has not been transformational
• Context and timeline are likely important
• Qualitative data suggest that support for
transformation will be important
• Applications that also change incentives
might have more traction
CCM Implementation: 4 Case Studies
Type of
Organization
Main CCM
Components
Introduced
Premier Health Partners
Network of
private practices
(100 physicians,
36 offices)
Decision support
tools, physician
performance
feedback
Increase in the proportion of diabetic patients
with HbA1c levels from 42% to 70%. Similar
improvements for foot examination results,
urine microalbumin levels, use of angiotensinconverting enzyme inhibitors
HealthPartners Medical
Group
Integrated
delivery system
Disease registry, case
management of highrisk patients, primary
care teams
Increase in the proportion of HPMG diabetic
patients with HbA1c levels <8% from 60.5% to
68.3%. Similar improvements in LDL-C
Levels.
Clinica Campesina
Community
health center
Self-management
training, disease
registry with
reminder system,
primary care teams
Average HbA1c levels of diabetic population
dropped from 10.5% to 8.6%. Improvements in
percentage of patients who received at least two
HbA1c tests in a year, eye examinations and
foot examinations. Increase in percentage of
patients with self-management goals.
Kaiser-Permanente
Northern California
Integrated
delivery system
Intensive treatment of
high-risk patients
Decrease in emergency department visits from
10 per 100 asthmatic patients to 4. Decrease in
percentage of asthma patients at high risk of an
acute event from 13.5% to 9.1%.
Name
Source: Bodenheimer, Wagner and Grumbach (2002). JAMA.
Outcome
We could also have more specific slides like this one for each of the 3 conditions
The Health Disparities Collaborative
Performance on Adjusted Quality-of-Care Measures, Diabetes Intervention
Intervention
x Internal
Control
Intervention
x External
Control
Assessment of smoking status and cessation advice
8
-2
Dilated eye examination
2
0
Foot examination
13**
21***
Assessment of nephropathy
29***
6
Influenza vaccination for patients with no egg allergy
12*
5
Dental examination
10**
10**
Assessment of glycated hemoglobin level
12**
16***
Use of ACE inhibitors or angiotensin-receptor blockers in patients
with proteinuria
5
-1
Lipid profile
4
-2
Use of daily aspirin
7
10*
Control of glycated hemoglobin level (<9%)
3
-3
Control of blood-pressure level (< 130/80mm Hg)
-2
-1
Control of LDL level
2
2
Measure Type Measure
Prevention &
Screening
Monitoring &
Assessment
Outcomes
* p<.05, ** p<.01, *** p<.001
Source: Landon et al (2007). NEJM.
Implementation and Maintenance of
QI for Depression in Primary Care
Changes made for each category of the Chronic Care Model
Model category of change
Changes
Implemented
Biggest
Successes
Changes
Sustained
N of
sites
% of
sites
N of
sites
% of
sites
N of
sites
% of
sites
Delivery system redesign
17
100
10
59
10
59
Self-management strategies
17
100
2
12
4
24
Decision support
16
94
6
35
6
35
Clinical information systems
17
100
9
53
16
94
Community linkages
15
88
2
12
3
18
Health system support
16
94
3
18
3
18
Mean +/- SD across six main categories and sites
16.3+/0.8
96.0+/4.9
5.3+/3.6
31.5+/20.8
7.0+/5.1
41.3+/
-30.8
Source: Meredith et al (2006). Psychiatric Services.