Appendix E: Selected Findings From Research on the Chronic Care Model
This appendix presents highlights from the scientific literature on each of
the six components of the Chronic Care Model, as well as on the Chronic Care
Model overall. The information presented here is not meant to be a comprehensive
review of the literature but rather to illustrate various health system changes
and their related impact or outcomes.
Chronic Care Model
Tsai and colleagues completed a meta-analysis of interventions to improve
care for chronic illnesses. This analysis was to determine whether interventions
that incorporate at least one element of the Chronic Care Model result in improved
outcomes for specific chronic illnesses and if any elements were essential
for improved outcomes. The meta-analysis on 112 studies revealed that
interventions with at least one element of the model had consistently beneficial
effects on clinical outcomes and processes of care across all conditions studied.
The effects on quality of life were mixed, with only the congestive heart failure
and depression studies showing benefit.
Source: Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis
of interventions to improve care for chronic illnesses. Am J Manag Care 2005
Aug;11(8):478-88.
Wagner and colleagues analyzed descriptive and pre-post data from 23 health
care organizations participating in the 13-month (August 1998-September 1999)
diabetes collaborative. Both chart review and self-report data on care
processes and clinical outcomes suggested improvements were based on health
system changes made during the collaborative. Many of the organizations with
the greatest improvements were community health centers, which had the fewest
resources and the most challenged populations.
Source: Wagner EH, Glasgow RE, Davis
C, et al. Quality improvement in chronic illness care: a collaborative approach.
Seattle, WA: MacColl
Institute for Healthcare Innovation. Accessed at http://www.improvingchroniccare.org on
December 12, 2006.
Health Care Organization
Although little research is currently available linking health care organization
components to direct improvement in health outcomes, there is evidence that
shows an indirect relationship. Evidence that implementation of the Chronic
Care Model does result in improved quality of care and improved health outcomes
has been noted elsewhere. The following are some examples of the indirect
linkage.
Visible leadership support. Ovretveit and colleagues
noted in their comprehensive review of research in quality collaboratives that
health care systems would be unlikely to achieve quality improvement that would
be significant or sustained in the absence of visible and real support from
senior leaders. Some examples of senior leader support include visiting
clinical sites, reviewing monthly reports, providing resources, and problem-solving
for innovators. Eventually, the support of change in pursuit of better
quality care should become part of the organization's culture.
Source: Ovretveit J, Bate P, Cleary P, et al. Quality collaboratives:
lessons from research. Qual Saf Health Care 2002;11:345-51.
Provider incentives. A 2002 report from the National
Health Care Purchasing Institute noted that provider incentives can be used
effective to improve health care quality and delivery. A range of incentive
models was examined. Although financial incentive models were the most
well known, there were several nonfinancial models, especially those that leveraged
the power of peer pressure. Organizations also combined several incentive
models to create a stronger motivation force for health care improvement.
Source: Bailit Health Purchasing LLC. Provider
Incentive Models for Improving Quality of Care. Washington, DC: National
Health Care Purchasing Institute; March 2002.
Self-Management Support
Asthma action plan and other self-management strategies. Lieu
and colleagues examined opportunities for intervention by identifying outpatient
management practices associated with increased risk of hospitalization or emergency
department (ED) visits among children under age 14 with asthma. Parents of
children hospitalized during the study period were less likely than those with
no hospitalization or ED visit to have a written asthma management plan and
to report washing bed sheets in hot water at least twice a month. Children
with hospitalization were also more likely to have a nebulizer.
Source: Lieu TA, Quesenberry CP Jr, Capra AM, et al. Outpatient
management practices associated with reduced risk of pediatric asthma hospitalization
and emergency department visits. Pediatrics 1997;100(3 Pt 1):334-41.
Asthma action plan. All asthma consensus statements
recommend the use of a written action plan as a central part of asthma management,
but a recent systematic review of randomized trials examined the independent
effect of a written action plan in children and adolescents and compared
the effect of different written action plans. Four trials involving 355 children
were reviewed. Children using symptom-based action plans had lower risk of
exacerbations which required an acute care visit. Children assigned to peak
flow-based action plans reduced by a half day the number of symptomatic days
per week.
Source: Bhogal S, Zemek R, Ducharme FM. Written action plans
for asthma in children. Cochrane Database Syst Rev 2006 Jul 19;3:CD005306.
Self-management education. This Cochrane review of
36 trials was conducted to examine the strength of evidence to test whether
health outcomes are influenced by education and self-management programs when
coupled with regular health practitioner review. Self-management education
reduced hospitalizations, emergency room visits, unscheduled visits to the
doctor, days off work or school, and nocturnal asthma. Researchers concluded
that education in asthma self-management which involves self-monitoring by
either peak flow or symptoms, coupled with regular medical review and a written
action plan, improves health outcomes for adults with asthma. Also, training
programs that enable people to adjust their medication using a written action
plan appear to be more effective than other forms of asthma self-management.
Source: Gibson PG, Powell H, Couglan J, et. al. Self-management
education and regular practitioner review for adults with asthma. Cochrane
Database Syst Rev 2003;(1):CD001117.
Health coaching. This study tested the efficacy of coaching
to reduce environmental tobacco smoke (ETS) exposure among Latino children
with asthma. After asthma management education, families were randomly assigned
to no additional service (control condition) or to coaching for ETS exposure
reduction (experimental condition). Approximately 1½ hours of asthma
management education was provided; experimental families also obtained seven
coaching sessions (approximately 45 minutes each) to reduce ETS exposure. At
4 months post-coaching, parents in the coached group reported their children
exposed to significantly fewer cigarettes than parents of control children. Reported
prevalence of exposed children decreased to 52% for the coached families
but only to 69% for controls.
Source: Hovell MF, Meltzer SB, Wahlgren DR, et. al. Asthma
management and environmental tobacco smoke exposure reduction in Latino children:
a controlled trial. Pediatrics 2002 Nov;110(5):946-56.
Delivery System Design
Physician education and nurse-led planned care. This
study compared two interventions (peer-led physician education vs. nurse-led
planned care plus peer leader education) across a 2-year period in real-world
primary care practices. Results demonstrated that an organized approach
to pediatric asthma care that includes the services of a nurse plus peer
leader education (planned care intervention) can significantly reduce asthma
symptom days by 12%, or an average of 13 days per year. According to
parent reports, planned care subjects also had greater controller adherence
compared with usual care subjects.
Source: Lozano P, Finkelstein JA, Carey V, et. al. A multisite
randomized trial of the effectiveness of physician education and organizational
change in chronic asthma care: health outcomes of the pediatric asthma care
patient outcomes research team II study. Arch Pediatr Adolesc Med
2004;158:875-83.
Group visits. The group visit model is one possible solution
to the limitations observed in the current primary care structure and to the
demands of the growing chronic illness load. An electronic review of all
group visit articles published from 1974 to 2004 was conducted via the PubMed® and
MEDLINE® databases. Although the heterogeneity of the studies presented
some limitations, there was sufficient data to support the effectiveness
of group visits in improving patient and physician satisfaction, quality
of care, quality of life, and in decreasing emergency department and
specialist visits.
Source: Jaber R, Braksmajer A, Trilling
JS. Group visits:
a qualitative review of current research. J Am Board Fam Med 2006
May-Jun;19(3):276-90.
Clinician prompting. This randomized controlled trial
examined whether clinician prompting regarding a child's symptom severity and
guideline recommendations at the time of an office visit improved the delivery
of preventive asthma care. Children were randomly assigned to a clinician-prompting
group (single-page prompt) or a standard-care group (no prompt given). Children
in the clinician-prompting group were more likely to have had preventive measures
at the visit compared with children in the standard-care group. These measures
included delivery of an action plan, discussions about asthma, and recommendations
for an asthma followup visit.
Source: Halterman JS, Fisher S, Conn KM, et al. Improved
preventive care for asthma: a randomized trial of clinician prompting in pediatric
offices. Arch Pediatr Adolesc Med 2006 Oct;160(10):1018-25.
Decision Support
Referral to asthma specialist. Asthma-specialist
care was compared to generalist care on the rate of relapse of asthma ED visits
and hospitalizations as well as on asthma control. Subjects ages 6-59 with
asthma presenting for acute ED care for asthma received either referral to
an asthma specialist in the allergy department with comprehensive ongoing asthma
care (experimental group) or continued outpatient management from generalist
physicians (control group). Compared with the control group, the intervention
group had a 75% reduction in the number of subjects with asthma awakenings
per night, an almost 50% reduction in asthma ED relapses, and a greater use
of inhaled corticosteroids and cromolyn.
Source: Zeiger RS, Heller S, Mellon MH, et al. Facilitated
referral to asthma specialist reduces relapses in asthma emergency room visits. J
Allergy Clin Immunol 1991 Jun; 87(6):1160-8.
Provider (resident) training. Researchers conducted
a pre- and post-training survey of 41 intervention residents to assess residents'
implementation of the Chronic Care Model. The change in implementation for
intervention residents was compared with that of 77 primary care residents
not receiving this training. Asthma-related ED use by patients cared for by
intervention residents was compared with that of other asthma patients. At
baseline, residents in both groups reported inconsistent application of key
elements of the model. At post-test, intervention-group residents reported significantly
greater increases in access to asthma guidelines, the proportion of patients
receiving written asthma management plans, and residents' access to information
on community asthma programs, than did comparison-group residents. The number of
asthma-related ED visits dropped significantly among patients treated by intervention
residents.
Source: Green J, Rogers VW, Yedidia MJ. The
impact of implementing a chronic care residency training initiative on asthma
outcomes. Acad
Med 2007 Feb;82(2):161-7.
Clinical Information Systems
There is a shortage of published research linking this component to direct
improvement in health outcomes and quality of care, but some evidence, as in
the following example, shows an indirect relationship.
Bates and colleagues reported that an information system was useful for measuring
care. In addition, it served as a useful tool for improving quality of
care when used for decision support. Investigators reported significant
benefits in reducing the unnecessary use of laboratory testing, quickly reporting
abnormal test results to key providers, preventing and detecting adverse drug
events, changing prescription patterns to reduce drug costs, and providing
critical pathways to providers.
Source: Bates DW, Pappius E, Kuperman
GJ, et al. Using information systems to measure and improve quality. Int J Med Inform. 1999
Feb-Mar;53(2-3):115-24 .
Community Resources and Policies
Community partnerships. This study evaluated the effectiveness
of a school-based asthma case management approach with medically underserved
inner city children. Fourteen elementary schools with high rates of asthma-related
hospital use were randomized to either a nurse case-management intervention
or a usual care condition. In intervention schools, nurse case managers conducted
weekly group sessions incorporating the "Open Airways" curriculum,
followed up on students' school absences, and coordinated students' asthma
care. In usual-care schools, students received routine school nursing services.
Students in the intervention schools had fewer school absences than their usual-care
counterparts (4 vs. 8 days, respectively) and experienced significantly fewer
ED visits and fewer hospital days.
Source: Levy M, Heffner B, Stewart T, Beeman G. The efficacy
of asthma case management in an urban school district in reducing school absences
and hospitalizations for asthma. J Sch Health 2006 Aug;76(6):320-4.
Lay workers. Use of community health workers to obtain
health, social, and environmental information from Black inner city children
with asthma was one component of a larger intervention study designed to reduce
morbidity in this group. A subset of 140 school-aged children with asthma
was recruited and enrolled in a program to receive home visits by health workers
for the purposes of obtaining medical information and teaching basic asthma
education to the families. Data gathered by the workers led researchers to
conclude that appropriately recruited and trained lay workers were effective
in obtaining useful medical information and providing basic asthma education
in the home.
Source: Butz AM, Malveaux FJ, Eggleston P, et. al. Use of
community health workers with inner-city children who have asthma. Clin
Pediatr (Phila) 1994 Mar;33(3):135-41.
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