1 The Effect of Primary Health Care Orientation on Chronic Illness Care Management Julie Schmittdiel, Ph.D., Stephen M. Shortell, Ph.D., Thomas Rundall, Ph.D. AcademyHealth Annual Research Meeting June 7, 2004 (Funded by Robert Wood Johnson Foundation Award #038690)

2 Introduction Chronic illness places huge burden on U.S. health care system: 125 million patients generate 75% of costs Chronic illness places huge burden on U.S. health care system: 125 million patients generate 75% of costs Institute of Medicine(2001) reports a “quality chasm” in chronic illness care provided to patients Institute of Medicine(2001) reports a “quality chasm” in chronic illness care provided to patients Improving chronic illness care delivery in the primary care setting has great potential for helping bridge chasm (Bodenheimer, Wagner and Grumbach 2002) Improving chronic illness care delivery in the primary care setting has great potential for helping bridge chasm (Bodenheimer, Wagner and Grumbach 2002)

3 Introduction, cont. Focus on acute problems and episodic care makes current primary care system ill-equipped to deal with chronic illness Focus on acute problems and episodic care makes current primary care system ill-equipped to deal with chronic illness A focus on comprehensive care and overall patient health (primary health care) could create an ideal environment for improved chronic illness care A focus on comprehensive care and overall patient health (primary health care) could create an ideal environment for improved chronic illness care Lack of empirical work examining whether greater primary health care orientation relates to improved chronic illness care processes Lack of empirical work examining whether greater primary health care orientation relates to improved chronic illness care processes

4 Research Question Does a physician organization’s primary health care orientation affect its delivery of chronic illness care?

5 The Chronic Care Model* (Wagner et al) Community Linkages: mobilize community resources for chronic illness patients Community Linkages: mobilize community resources for chronic illness patients Health System Organization: leadership commitment to chronic illness care and its outcome Health System Organization: leadership commitment to chronic illness care and its outcome Patient Self-Management Support: encourage lifestyle changes and developing of illness management skills Patient Self-Management Support: encourage lifestyle changes and developing of illness management skills Delivery System Design: offer team-based care and patient follow-up Delivery System Design: offer team-based care and patient follow-up Decision Support for Providers: train providers in evidence- based guidelines and give access to specialist expertise Decision Support for Providers: train providers in evidence- based guidelines and give access to specialist expertise Clinical Information Systems: electronic medical data systems; use for provider feedback, reminders, and care planning Clinical Information Systems: electronic medical data systems; use for provider feedback, reminders, and care planning *See for more details

6 Primary Health Care (Starfield 1992) 1. First Contact: primary care providers provide window to use of specialists 2. Continuity: primary care provider/patient relationship is long-term and consistent 3. Comprehensiveness: primary care provides wide range of services across settings 4. Coordination: primary care coordinates with care from other sources 5. Accountability : primary care providers feel ultimately responsible for overall patient health

7 Research Hypothesis Similarities across concepts suggest that organizations practicing primary health care may be more committed to the Chronic Care Model. Similarities across concepts suggest that organizations practicing primary health care may be more committed to the Chronic Care Model. Research Hypothesis: Physician organizations with a high degree of overall primary health care orientation will have a higher degree of Chronic Care Model implementation. Research Hypothesis: Physician organizations with a high degree of overall primary health care orientation will have a higher degree of Chronic Care Model implementation.

8 Data Source National Study of Physician Organizations* (NSPO) Cross-sectional survey of all U.S. physician organizations with 20 or more MDs Cross-sectional survey of all U.S. physician organizations with 20 or more MDs Data collected from Sept Sept Data collected from Sept Sept Assessed chronic illness care processes, IT, external incentives, organizational/financial characteristics Assessed chronic illness care processes, IT, external incentives, organizational/financial characteristics 70% response rate; n=64 treating no chronic illness deleted 70% response rate; n=64 treating no chronic illness deleted Result of n=1,040 organizations for analysis Result of n=1,040 organizations for analysis *further information and survey instrument available at

9 Dependent Variable: Chronic Care Model Index 11-point Chronic Care Model Index Mean(SD) 4.6 (2.9) Agreements with Comm. Services Agencies Agreements with Comm. Services Agencies20.2% Referrals to Comm. Services Agencies Referrals to Comm. Services Agencies32.4% Assess Self-Management Needs Assess Self-Management Needs44.8% Self-Management Programs Self-Management Programs56.6% Integrate Guidelines into Care Integrate Guidelines into Care51.4% Integrate Specialists into Care Integrate Specialists into Care62.2% Utilize Planned Visits Utilize Planned Visits56.0% Multiple Providers Seen in one Visit Multiple Providers Seen in one Visit36.3% Employ Case Managers Employ Case Managers34.2% Written Feedback to MDs Written Feedback to MDs36.6% Internet Comm. between MDs and Patients Internet Comm. between MDs and Patients25.9%

10 Independent Variables: Primary Health Care Orientation Comprehensiveness: Comprehensiveness: Severe Chronic Illness Treated in Primary Care Severe Chronic Illness Treated in Primary Care (range 0-4) mean (SD) (range 0-4) mean (SD).50 (.90) Health Promotions Index (range 0-8) mean (SD) Health Promotions Index (range 0-8) mean (SD) 2.5 (2.6) Patient Education Index (range 0-4) mean (SD) Patient Education Index (range 0-4) mean (SD) 2.4 (1.5) Coordination: Coordination: Use of Electronic Medical Record (% yes) Use of Electronic Medical Record (% yes)21.0% Use of Electronic Standardized Problem List (% yes) Use of Electronic Standardized Problem List (% yes)17.7% Accountability: Accountability: Required Outside Reporting Index (range 0-4) mean (SD) Required Outside Reporting Index (range 0-4) mean (SD) 0.8 (1.4) % Patients PO Accepts Risk for Hospital Costs mean (SD) % Patients PO Accepts Risk for Hospital Costs mean (SD) 22.0 (36.3) Continuity: Continuity: Primary Care Physician % Turnover Rate – mean (SD) Primary Care Physician % Turnover Rate – mean (SD) 5.7 (8.4)

11 Method of Analysis: Multivariate Linear Regression Chronic Care Model Implementation Index = f(Primary Health Care Orientation Variables, control variables*) *controlling for organization age, size, number of clinics, region, ownership, organization type, capitalization, county-level HMO penetration

12 Analysis Results Primary Health Care Orientation Variables B (S.E) Comprehensiveness: Severe Chronic Illness Treated in Primary Care.21* (.08) Health Promotions Index.39***(.03) Patient Education Index.28*** (.05) Coordination: Use of Electronic Medical Record.30 (.23) Use of Electronic Standardized Problem List.51* (.23) Accountability: Required Outside Reporting Index.25** (.06) % Patients PO Accepts Risk for Hospital Costs.006*(.002) Continuity: Primary Care Physician % Turnover Rate -.01 (.009) *** = p<.001; ** = p<.01; * = p<.05

13 Summary of Results Strong support for Research Hypothesis Strong support for Research Hypothesis Six of eight primary health care orientation variables significantly related to index of Chronic Care Model implementation Six of eight primary health care orientation variables significantly related to index of Chronic Care Model implementation Low levels of primary health care orientation in U.S. physician organizations Low levels of primary health care orientation in U.S. physician organizations Limited use of Chronic Care Model Limited use of Chronic Care Model

14 Health Policy Implications Empirical justification for improving chronic illness care within a primary health care setting Empirical justification for improving chronic illness care within a primary health care setting Increasing primary health care orientation in physician organizations may improve chronic illness care processes Increasing primary health care orientation in physician organizations may improve chronic illness care processes By facilitating changes in the primary care system, stakeholders could benefit people with chronic illness By facilitating changes in the primary care system, stakeholders could benefit people with chronic illness

15 Conclusion Chronic illness places a great burden on health care system Chronic illness places a great burden on health care system This and other research demonstrates much room to improve quality of chronic illness care This and other research demonstrates much room to improve quality of chronic illness care Creating a health care system with a greater primary health care orientation may help bridge quality chasm in chronic illness care Creating a health care system with a greater primary health care orientation may help bridge quality chasm in chronic illness care