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1 Center for Research Strategies, Denver, Colo
2 Department of Family Medicine, University of Colorado Health Sciences Center, Denver, Colo
3 Clinical Research Unit, Kaiser Permanente Colorado, Denver, Colo
4 Department of Family Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ
5 Cancer Institute of New Jersey, UMDNJ School of Public Health, New Brunswick, NJ
CORRESPONDING AUTHOR: Paul A. Nutting, MD, MSPH, Center for Research Strategies, 225 E 16th Ave, Denver, CO 80203, Paul.Nutting{at}CRSLLC.org
PURPOSE In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients’ hemoglobin A1c (HbA1c) and lipid levels and self-reported receipt of care.
METHODS Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician’s assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA1c; foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA1c values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data.
RESULTS Clinician-reported use of elements of CCM was significantly associated with lower HbA1c values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from "rarely" to "occasionally"), there was an associated 0.30% reduction in HbA1c value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07).
CONCLUSIONS Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.
Key Words: Diabetes mellitus • Chronic Care Model • primary care physicians • quality of health care • quality improvement • process assessment (health care) • chronic diseases • health services research
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