Impact of care management processes and integration of care on blood pressure control in diabetes

Abstract

BackgroundFragmentation within health care systems may negatively impact the quality of chronic disease patient care. We sought to evaluate the relationship between care management processes (CMP), integration of services, and blood pressure (BP) control among diabetic patients.MethodsRetrospective chart reviews were performed for a random sample of adult diabetic hypertensive patients (n = 2,162) from 28 physician organizations in the United States (US). A modified version of the Physician Practice Connection Readiness Survey (PPC-RS) was completed by the chief medical officer at each site. The PPC-RS measured health system organization, delivery system redesign, decision support, clinical information systems, and self-management support, and an integration scale measured structure, functions, and financial risk. Correlations between PPC and integration scores and BP outcomes were assessed using Spearman correlation coefficients.ResultsApproximately 39.9% of diabetic patients had controlled BP. Mean total PPC score across sites was 55, with highest mean scores for health system organization (81), followed by design support (60), clinical information systems (57), self-management support (39), and delivery system redesign (39). Mean integration score was 46 (SD 27, range 4–93), and means of subscores were 64 for structure, 33 for financial risk, and 42 for function. Clinical information systems subscore was correlated with uncontrolled BP (r = −0.38, p < 0.05), while association with total PPC score was strong but not significant at p < 0.05 (r = −0.32). Total integration score and the structure subscore were significantly correlated with BP control (r = 0.38, p < 0.05, and r = 0.49, p < 0.01).ConclusionsThis study suggests that CMP and service integration may be associated with better outcomes in diabetes, though results were mixed and limited by a small number of participating sites. Primary care implementation of integrated electronic medical records may have a beneficial effect on patient outcomes for diabetes and other chronic diseases.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review

“…The majority of studies focused on the provision of care for diabetes [ 21 , 24 , 26 , 27 , 29 , 31 , 33 - 38 , 40 - 42 , 44 - 53 , 55 - 60 , 62 , 65 - 70 , 72 , 75 , 76 , 79 , 80 , 83 - 87 , 90 , 91 , 93 , 94 , 96 ]. Included studies also focused on cardiovascular disease [ 20 , 25 , 28 , 30 , 32 , 39 , 43 , 54 , 61 , 63 , 64 , 71 , 73 , 88 , 89 , 91 , 95 ], depression [ 34 , 51 , 53 , 74 , 76 , 90 ], respiratory disease [ 90 ], including chronic obstructive pulmonary disease [ 77 , 81 , 82 , 92 , 93 ], and renal disease [ 21 , 90 ].…”

“…In a small number of studies [ 35 , 70 , 75 ] the Assessment of Chronic Illness Care (ACIC) was used to assess level of implementation of CCM elements in primary healthcare settings. The ACIC contains 28 items across the six elements within the Wagner CCM: CS, HS, SMS, DS, DSD and CIS, with each assigned a numeric score from 0 to 11.…”

“…Eight of the 11 cross-sectional studies [ 13 , 35 , 40 , 45 , 46 , 66 , 70 , 87 ] either did not have sufficient information to make an assessment, or were considered to be at high risk of selection bias. Only four of the cross-sectional studies met the criteria for being at low risk of detection [ 45 - 47 , 70 ] or attrition biases [ 35 , 46 , 60 , 70 ], while seven were assessed as low risk for reporting bias [ 35 , 45 - 47 , 60 , 75 , 87 ] [see Additional file 1 : Table S4].…”

Process Evaluation of Implementation Fidelity of the Integrated Chronic Disease Management Model in Two Districts, South Africa

“…However, studies that have looked at implementation of other chronic diseases management models, highlighted a high variability in the combination of components included the chronic disease models and the ways in which they are implemented [43,48]. In our study, the overall level of implementing the chronic care model elements according to guidelines varied between 55-89% [48][49][50]. The highest (89%) level of fidelity observed was in a continuum of care programme, with 16 of the 18 components implemented according to the guidelines [48].…”

“…Lack of clinical leadership could adversely affect the expected outcomes and sustainability of the ICDM model [32,38]. Redesign of service delivery, integration of services and decision support were also inadequately implemented in other chronic care models evaluations, with scores of 39-46%; 46% and 58% respectively [49,50]. Clinical management decision support should be enhanced in this setting where nurses' knowledge on chronic diseases is inadequate and guidelines are not readily available [54][55][56][57].…”