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Survey Item Chronic Care Model Element Addressed Score Mean (SD) Note: Ninety primary care clinicians provided self-reported information for 9 survey items inquiring about use of selected Chronic Care Model elements. The stem question asked, “How often do you currently use the following approaches to improving care for patients with diabetes?” Response options were never = 1, rarely = 2, occasionally = 3, usually = 4, and always = 5. a. Use a registry to identify and/or track care of your patients Clinical information systems 2.53 (1.33) b. Use a tracking system to remind patients about needed visits or services Clinical information systems 3.60 (0.93) c. Follow up patients between visits by telephone (you or staff) Practice design 3.11 (0.74) d. Use published practice guidelines as the basis for your management Decision support 4.02 (0.80) e. Involve office staff in identifying and reminding patients in need of follow-up or other services Practice design 3.65 (0.99) f. Assist patients in setting and attaining self-management goals Self-management support 3.74 (0.87) g. Refer patients to someone within your practice for education about their diabetes Self-management support 2.85 (1.41) h. Refer patients to someone outside your practice for education about their diabetes Decision support 3.15 (1.02) i. Use flow sheets to track critical elements of care Decision support 3.51 (1.25) - Table 2.
Multivariate, Multilevel Regression Model Showing Association of Clinician Use of Chronic Care Model Elements and 2 Measures of Process of Diabetes Care
Parameter Parameter Estimate* SE P Value PHQ-9 = 9-item Patient Health Questionnaire; CCM = Chronic Care Model. * The parameter estimates indicate the strength of the association in each model. Each unit difference in clinician-reported frequency of CCM use (eg, from “rarely” to “occasionally”) is associated with a change in the dependent variable (behavioral care composite score or clinical care composite score) equal to the parameter estimate. † Covariates included patient age, race/ethnicity, and severity of depressive symptoms (PHQ-9 score). ‡ Covariates included patient age and race/ethnicity. Behavioral care composite score† Intercept 1.7038 0.2891 <.001 Patient age −0.0054 0.0029 .07 Patient race/ethnicity: white (vs nonwhite) 0.1483 0.0927 .11 Patient PHQ-9 (depression) score −0.0130 0.0074 .08 Clinician score for use of CCM 0.2105 0.0595 .001 Clinical care composite score‡ Intercept 2.8214 0.3672 <.001 Patient age 0.0066 0.0031 .03 Patient race/ethnicity: white (vs nonwhite) 0.1418 0.0958 .14 Clinician score for use of CCM 0.1592 0.0868 .07 - Table 3.
Multivariate, Multilevel Regression Model Showing Association of Clinician Use of Chronic Care Model Elements and 2 Measures of Diabetes Care Intermediate Outcomes
Parameter Parameter Estimate* SE P Value CCM = Chronic Care Model; HDL = high-density lipoprotein. * The parameter estimates indicate the strength of the association in each model. Each unit difference in clinician-reported frequency of CCM use (eg, from “rarely” to “occasionally”) is associated with a change in the dependent variable (hemoglobin A1c value or lipid ratio) equal to the parameter estimate. † Analyzed as a continuous variable. Covariates included patient age, patient race/ethnicity, clinician sex, and clinician specialty. ‡ Analyzed as a continuous variable. Covariates included patient age and marital status. Hemoglobin A1c value† Intercept 9.3118 0.5709 <.001 Patient age −0.0082 0.0041 .049 Patient race/ethnicity: white (vs nonwhite) −0.5990 0.1290 <.001 Clinician sex: female −0.3371 0.1318 .01 Clinician specialty Physician’s assistant −0.6152 0.4299 .16 Nurse-practitioner 0.8065 0.2556 .003 General internal medicine 0.1901 0.1263 .14 Family physician (reference) – – – Clinician score for use of CCM −0.3013 0.0879 .002 Lipid ratio (total cholesterol:HDL-cholesterol)‡ Intercept 5.8541 0.3414 <.001 Patient age −0.0148 0.0035 <.001 Patient marital status: married 0.1589 0.0967 .10 Clinician score for use of CCM −0.1663 0.0690 .02
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The Article in Brief
Use of Chronic Care Model Elements is Associated With Higher Quality Care for Diabetes
Paul A. Nutting, MD, MSPH , and colleagues
Background The Chronic Care Model is a comprehensive approach to caring for people with chronic diseases. This report explores whether there is a relationship between certain elements of the Chronic Care Model and the care of diabetes patients. The study included 90 clinicians (doctors, nurse-practitioners, and physician's assistants) and 886 patients.
What This Study Found Clinicians� use of certain elements of the chronic care model, such as systems of tracking and following up with diabetes patients, was related to lower hemoglobin A1c (a measure of overall diabetes control) and lower cholesterol levels in diabetes patients, two indicators of good diabetes management.
Implications
- There is growing evidence that elements of the Chronic Care Model improve the care of patients with chronic disease in primary care settings.
- Clinicians in small, independent primary care practices are able to incorporate aspects of the Chronic Care Model into their practice style, often without making major changes in their practice, and this is related to higher levels of diabetes care and better health of diabetes patients.
- Small primary care practices might consider more ambitious efforts to change the ways in which they care for patients with chronic illnesses.
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