Research ArticleOriginal Research

Effect of Primary Health Care Orientation on Chronic Care Management

Julie A. Schmittdiel, Stephen M. Shortell, Thomas G. Rundall, Thomas Bodenheimer and Joe V. Selby
The Annals of Family Medicine March 2006, 4 (2) 117-123; DOI: https://doi.org/10.1370/afm.520

Article Figures & Data

Tables

  • Table 1.

    Characteristics of Physician Organizations

    CharacteristicTotal (N = 957)
    IPA = independent practice association; MD = medical doctor; HMO = health maintenance organization.
    * As defined in the American Medical Association census (Havlicek PI. Medical Groups in the US, 1999. Chicago, Ill: American Medical Association; 1999).
    Organizational type, No. (%)
        Medical group621 (64.9)
        IPA336 (35.1)
    Ownership type, No. (%)
        Hospital/health plan376 (39.3)
        MD456 (47.6)
        Other125 (13.1)
    Region,* No. (%)
        East North Central169 (17.7)
        East South Central45 (4.7)
        Middle Atlantic101 (10.6)
        Mountain59 (6.2)
        Northeast58 (6.1)
        Pacific245 (25.6)
        South Atlantic118 (12.3)
        West North Central81 (8.4)
        West South Central81 (8.4)
    Practice location, No. (%)
        Urban/suburban665 (69.5)
        Rural/small town292 (30.5)
    Age of organization, mean (SD), y25.7 (21.9)
    No. of MDs, mean (SD)239.9 (424.1)
    No. of clinic sites, mean (SD)77.9 (266.6)
    County HMO penetration, mean (SD), %33.1 (17.2)
    Physicians who are primary care physicians, mean (SD), %50.9 (28.2)
    Capital per MD, log, mean (SD)120,706.7 (359,996.0)
  • Table 2.

    Measures of CCM Implementation Among Physician Organizations

    MeasureTotal (N = 957) No. (%)
    CCM = Chronic Care Model; Q = question; CCMI = Chronic Care Model Index.
    Community linkages
        Q55a: Agreements with community services agencies200 (20.9)
        Q55b: Referrals to community agencies313 (32.7)
    Self-management support
        Q56a: Assess self-management needs423 (44.2)
        Q56b: Self-management programs542 (56.6)
    Decision support
        Q57a: Integrate guidelines into care499 (52.1)
        Q57b: Integrate specialists into care615 (64.3)
    Delivery system design
        Q58a: Use planned visits536 (56.0)
        Q58b: Multiple professionals seen in 1 visit335 (35.0)
        Q58c: Employ case managers346 (36.2)
    Information systems
        Q59a: Written feedback to physicians349 (36.5)
        Q59b: Internet communication between physicians and patients250 (26.1)
    Overall
        Use of any CCM element865 (90.4)
        Use of all 11 CCM elements12 (1.3)
        CCMI, mean (SD)4.6 (2.9)
  • Table 3.

    Measures of Primary Health Care Orientation Among Physician Organizations

    MeasureTotal (N = 957)
    * Possible range, 0 to 4.
    † Possible range, 0 to 8.
    Continuity/longitudinality
        Primary care physician turnover rate over 5 years, mean (SD), %5.7 (8.4)
    Comprehensiveness
        Severe chronic illness treated in primary care index, mean (SD)*0.5 (0.9)
        Health promotions index, mean (SD)†2.5 (2.6)
        Health education index, mean (SD)*2.4 (1.5)
    Coordination
        Presence of electronic medical record, No. (%)188 (19.6)
        Presence of electronic standardized problem list, No. (%)168 (17.6)
    Accountability
        Required outside reporting index, mean (SD)*0.8 (1.4)
        Physician organization accepts any financial risk for hospital costs, No. (%)406 (42.4)
  • Table 4.

    Multivariate Linear Regression Analysis Predicting CCMI

    Variableβ Coefficient (SE)
    CCMI = Chronic Care Model Index; MD = medical doctor; IPA = independent practice association; HMO = health maintenance organization.
    Note: Adjusted R2 = .35.
    * Possible range, 0 to 4.
    † Possible range, 0 to 8.
    ‡ P <.05
    § P <.01
    ¶ P <.001
    Primary health care orientation measures
    Comprehensiveness
        Severe chronic illness treated in primary care index*.24§ (.09)
        Health promotions index†.39 (.04)
        Health education index*.31 (.06)
    Accountability
        Physician organization accepts any financial risk for hospital costs vs none.56§ (.18)
        Required outside reporting index*.22 (.06)
    Continuity/longitudinality
        Primary care physician turnover rate over 5 years, %−.01 (.009)
    Coordination
        Presence of electronic medical record.27 (.24)
        Presence of electronic standardized problems list.49‡ (.25)
    Control variables
    Urban/suburban vs rural/small town.002 (.20)
    Age of organization, y.005 (.004)
    No. of MDs.0006§ (.0002)
    No. of clinic sites−.0003 (.0003)
    Ownership (vs MD)
        Hospital/health plan.04 (.20)
        Other.49 (.26)
    Pacific region vs all others.39 (.21)
    Medical group vs IPA1.18 (.24)
    Capital per MD, log.005 (.02)
    County HMO penetration, %.008 (.005)

Additional Files

  • Supplemental Appendix

    PDF file, 3 pages, 82 KB

    Files in this Data Supplement:

  • The Article in Brief

    Background Chronic illness is a major health crisis in the United States, and evidence suggests there is a great need to improve the quality of chronic illness care. One way to improve chronic illness care may be to emphasize comprehensive, coordinated primary care. This study examines whether medical practices and groups that are oriented toward providing primary care also demonstrate features of the Chronic Care Model, a widely-recognized model that identifies elements of health care that encourage effective care of chronic illnesses.

    What This Study Found Medical practices and groups that have 6 core features of primary care, representing comprehensive health service delivery and a commitment to overall patient health, also have more features of the Chronic Care Model.

    Implications

    • These findings support the need for patients to have a primary care ��home�� to strengthen management of chronic care illness.
    • Efforts by policy makers and payers to increase medical organizations� focus on primary care may improve chronic illness care.
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