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)
1
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)
2
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
3
Research Question
Does a physician organization’s 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 evidencebased 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)
1.
2.
3.
4.
5.
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; n=64 treating no chronic illness deleted

Result of n=1,040 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)
Health Promotions Index (range 0-8) mean (SD)
Patient Education Index (range 0-4) mean (SD)
Coordination:
Use of Electronic Medical Record (% yes)
Use of Electronic Standardized Problem List (% yes)
.50 (.90)
2.5 (2.6)
2.4 (1.5)
21.0%
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
Comprehensiveness:
Severe Chronic Illness Treated in Primary Care
Health Promotions Index
Patient Education Index
Coordination:
Use of Electronic Medical Record
Use of Electronic Standardized Problem List
Accountability:
Required Outside Reporting Index
% Patients PO Accepts Risk for Hospital Costs
Continuity:
Primary Care Physician % Turnover Rate
*** = p<.001; ** = p<.01; * = p<.05
B (S.E)
.21* (.08)
.39***(.03)
.28*** (.05)
.30 (.23)
.51* (.23)
.25** (.06)
.006*(.002)
-.01 (.009)
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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
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