Research ArticleOriginal ResearchA

Care Quality and Implementation of the Chronic Care Model: A Quantitative Study

Leif I. Solberg, A. Lauren Crain, JoAnn M. Sperl-Hillen, Mary C. Hroscikoski, Karen I. Engebretson and Patrick J. O’Connor
The Annals of Family Medicine July 2006, 4 (4) 310-316; DOI: https://doi.org/10.1370/afm.571

Article Figures & Data

Tables

  • Table 1.

    ACIC Score Changes After Implementation

    Dimension20022004ChangeP ValueRange
    ACIC = Assessing Chronic Illness Care.
    No. of clinics161716
    Overall5.87.21.4.02−2.6 to +5.4
    Delivery system design5.76.81.2.11−3.0 to +5.1
    Self-management support6.17.01.1.08−4.0 to +3.8
    Clinical information system5.26.71.6.01−1.2 to +6.1
    Decision support6.07.31.4.10−3.5 to +7.5
    Delivery organization6.48.01.7.01−3.8 to +5.7
    Community linkages5.77.21.6.03−3.3 to +6.3
  • Table 2.

    Overall ACIC Score Changes by Clinic

    Clinic20022004Change
    ACIC = Assessing Chronic Illness Care.
    11.76.54.8
    25.45.3−0.1
    35.97.61.7
    45.08.43.4
    55.06.31.3
    67.27.30.1
    79.59.80.3
    88.45.8−2.6
    9–5.4–
    106.57.51.1
    114.97.93.0
    124.67.42.8
    134.74.0−0.7
    149.07.4−1.5
    153.89.25.4
    166.79.72.9
    175.26.10.9
    Mean (SD)5.8 (2.0)7.2 (1.6)1.4 (2.2)
    Range1.7 to 9.54.0 to 9.8−2.6 to 5.4
  • Table 3.

    Quality Measure Changes From 2002–2004 (n = 17)

    Measures20022004ChangeClinic RangeP Value
    Diabetes
        Number7,4237,650145–826
        Composite process, %63.563.1−0.4−9.1 to +7.4.70
        Composite high (8/130), %43.952.4+8.5+4.2 to +16.3.001
        Composite low (7/100), %15.725.5+9.8+4.3 to +17.7.001
    Heart Disease
        Number3,7263,76155–473
        Composite control, %46.857.8+11.1+2.9 to +19.2.001
        Cardiac event rate, %17.211.4−5.9−13.5 to +1.9.001
    Depression
        Number3,1542,78837–400
        Acute phase (>84 d), %68.069.1+1.1−5.6 to +8.7.39
        Continuation phase (>180 d), %51.251.9+0.6−8.4 to +9.1.61
        No primary care follow-up visit, %14.510.9−3.5−13.1 to +11.2.02
  • Table 4.

    Correlations Between Change in ACIC and Change in Quality Measures

    MeasureOverallHealth Care OrganizationDelivery System DesignSelf-Management SupportClinical Information SystemDecision SupportCommunity Linkage
    ACIC = Assessing Chronic Illness Care.
    * P <.05
    Diabetes
        Composite process+0.17+0.20+0.33+0.21+0.01+0.03+0.14
        Composite high+0.28+0.17+0.21+0.16+0.44+0.32+0.12
        Composite low+0.42+0.37+0.17+0.34+0.50*+0.54*+0.25
    Heart disease
        Composite control−0.23+0.08−0.26−0.18−0.29−0.15−0.40
        Cardiac events−0.01−0.07+0.16+0.07−0.06+0.01−0.18
    Depression
        Acute phase−0.26−0.07−0.31−0.35−0.30−0.02−0.38
        Continuation phase+0.05+0.09+0.02+0.06−0.14+0.22−0.08
        No primary care follow-up visit−0.10−0.20−0.02−0.12+0.05−0.13−0.10

Additional Files

  • The Article in Brief

    Care Quality and Implementation of the Chronic Care Model: A Quantitative Study

    Leif I. Solberg, MD , and colleagues

    Background A new approach is needed to improve the care of people with chronic diseases. The Chronic Care Model (description below) is widely accepted as a method for providing better care for chronically ill people. This study is one of the first to assess the efforts of a large medical group in implementing the Chronic Care Model (CCM). In particular, the study examined whether implementation of the CCM was associated with quality of care for patients with 3 common chronic conditions: diabetes, heart disease and depression.

    (Description: From: http://www.improvingchroniccare.org/change/model/components.html: �The Chronic Care Model identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.�)

    What This Study Found During a 2-year period, the medical group improved its implementation of most elements of the CCM and its quality of care for patients with diabetes and heart disease. (There was little improvement in quality of care for patients with depression). However, there does not appear to be a relationship between implementation of the CCM and quality improvements for people with these conditions.

    Implications

    • Demonstrating a relationship between implementation of the CCM and improvements in quality measures for 3 chronic diseases may require larger changes, more participating clinics, changes in other CCM elements, or more sensitive measurement tools.
    • Additional research is needed to help identify which interventions and care changes matter the most and how they are best implemented.

  • Annals Journal Club Selections:

    Jul/Aug 2006

    The Annals Journal Club is designed to encourage a learning community of those seeking to improve health care and health through enhanced primary care. Additional information is available on the Journal Club home page.

    Articles for Discussion

    • Solberg LI, Crain AL, Sperl-Hillen JM, Hroscikoski MC, Engebretson KI, O�Connor PJ. Care quality and implementation of the Chronic Care Model: a quantitative study. Ann Fam Med. 2006;4:310-316.
    • Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail M, Crabtree BF. The challenges of change: implementing the Chronic Care Model. Ann Fam Med. 2006;4:317-326.

    Discussion Tips

    This issue of Annals features multimethod research that integrates both quantitative and qualitative methods. These methods have complementary strengths and weaknesses, and their conjoint use often can provide a fuller picture than studies using either type of method alone.1 The intervention being evaluated in the articles for this journal club is based on the Chronic Care Model.2 This theoretical framework is being widely used to develop infrastructure to promote informed, activated patients interacting with a prepared, proactive practice team to improve patients� functional and clinical outcomes.

    Discussion Questions

    1. What is the Chronic Care Model, and why might it matter (http://improvingchroniccare.org/change/model/components.html)?
    2. Was the design of each study appropriate to its research question?
    3. What designs and measures would be stronger?
    4. What characteristics of the study practices and health care system are different from your practice in ways that affect the transportability of the findings?
    5. To what degree can the findings be accounted for by:
      • Inadequate sample size?
      • Selection bias in who was included in the study?
      • Poorly measured or irrelevant constructs?
      • Poor implementation of the model?
      • High baseline performance in the participating practices?
      • Changes not attributable to the intervention?
    6. What are the strengths and weaknesses of the quantitative study (Solberg et al)? What are the strengths and weaknesses of the qualitative study (Hroscikoski et al)? How do the strengths of one bolster the weaknesses of the other?
    7. What are some relative weakness in your practice�s ability to provide good chronic care (see the elements of the Chronic Care Model in Solberg or Figure 1 in Hroscikoski)? What office systems or other process changes would improve chronic care? Which changes would have the greatest impact on quality of chronic care? Which changes would be easy to implement?
    8. Given the lessons learned by the authors, what would be your strategy for making change in your practice?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals journal club: It�s time to get RADICAL. Ann Fam Med. 2006;4:196-197. Available at: http://annfammed.org/cgi/content/full/4/3/196.
    2. Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. 2001;27:63-80.
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