Introduction
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
„
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”
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)
(Funded by Robert Wood Johnson Foundation Award #038690)
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Introduction, cont.
„
Research Question
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
Does a physician organization’
organization’s primary
health care orientation affect its delivery
of chronic illness care?
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The Chronic Care Model* (Wagner et al)
Primary Health Care (Starfield 1992)
„
Community Linkages: mobilize community resources for
chronic illness patients
1.
„
Health System Organization: leadership commitment to
chronic illness care and its outcome
2.
„
Patient SelfSelf-Management Support: encourage lifestyle changes
and developing of illness management skills
3.
„
Delivery System Design: offer teamteam-based care and patient
followfollow-up
4.
„
Decision Support for Providers: train providers in evidenceevidencebased guidelines and give access to specialist expertise
5.
„
Clinical Information Systems: electronic medical data systems;
use for provider feedback, reminders, and care planning
First Contact:
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
*See www.improvingchroniccare.org for more details
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Research Hypothesis
Data Source
National Study of Physician Organizations* (NSPO)
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.
„
CrossCross-sectional survey of all U.S. physician organizations with
20 or more MDs
„
Data collected from Sept. 20002000-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
http://nspo.berkeley.edu
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Dependent Variable:
Chronic Care Model Index
1111-point Chronic Care Model Index Mean(SD)
Mean(SD)
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Independent Variables:
Primary Health Care Orientation
4.6 (2.9)
Agreements with Comm. Services Agencies
20.2%
Comprehensiveness:
Severe Chronic Illness Treated in Primary Care
(range 00-4) mean (SD)
Referrals to Comm. Services Agencies
32.4%
Health Promotions Index (range 00-8) mean (SD)
Assess SelfSelf-Management Needs
44.8%
SelfSelf-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%
Patient Education Index (range 00-4) mean (SD)
Coordination:
Use of Electronic Medical Record (% yes)
Use of Electronic Standardized Problem List (% yes)
Accountability:
Required Outside Reporting Index (range 00-4) mean (SD)
.50 (.90)
2.5 (2.6)
2.4 (1.5)
21.0%
17.7%
0.8 (1.4)
% Patients PO Accepts Risk for Hospital Costs mean (SD) 22.0 (36.3)
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Method of Analysis:
Multivariate Linear Regression
Continuity:
Primary Care Physician % Turnover Rate – mean (SD)
5.7 (8.4)
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Analysis Results
Primary Health Care Orientation Variables
Comprehensiveness:
Severe Chronic Illness Treated in Primary Care
Chronic Care Model Implementation Index =
f(Primary Health Care Orientation Variables,
control variables*)
Health Promotions Index
Patient Education Index
Coordination:
Use of Electronic Medical Record
Use of Electronic Standardized Problem List
*controlling for organization age, size, number of
clinics, region, ownership, organization type,
capitalization, county- level HMO penetration
Accountability:
Required Outside Reporting Index
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B (S.E)
.21* (.08)
.39***(.03)
.28*** (.05)
.30 (.23)
.51* (.23)
% Patients PO Accepts Risk for Hospital Costs
.25** (.06)
.006*(.002)
Continuity:
Primary Care Physician % Turnover Rate
-.01 (.009)
*** = p<.001; ** = p<.01; * = p<.05
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Summary of Results
„
Health Policy Implications
Strong support for Research Hypothesis
„
Six of eight primary health care orientation
variables significantly related to index of Chronic
Care Model implementation
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Low levels of primary health care orientation
in U.S. physician organizations
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Limited use of Chronic Care Model
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„
Empirical justification for improving chronic
illness care within a primary health care setting
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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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