Implementation of the Chronic Care Model in Small Medical Practices Improves Cardiovascular Risk but Not Glycemic Control

Abstract

OBJECTIVETo test whether the implementation of elements of the Chronic Care Model (CCM) via a specially trained practice nurse leads to an improved cardiovascular risk profile among type 2 diabetes patients. RESEARCH DESIGN AND METHODSThis cluster randomized controlled trial with primary care physicians as the unit of randomization was conducted in the German part of Switzerland. Three hundred twenty-six type 2 diabetes patients (age >18 years; at least one glycosylated hemoglobin [HbA 1c ] level of ‡7.0% [53 mmol/mol] in the preceding year) from 30 primary care practices participated. The intervention included implementation of CCM elements and involvement of practice nurses in the care of type 2 diabetes patients. Primary outcome was HbA 1c levels. The secondary outcomes were blood pressure (BP), LDL cholesterol, accordance with CCM (assessed by Patient Assessment of Chronic Illness Care [PACIC] questionnaire), and quality of life (assessed by the 36-item short-form health survey ). RESULTSAfter 1 year, HbA 1c levels decreased significantly in both groups with no significant difference between groups (20.05% [20.60 mmol/mol]; P = 0.708). Among intervention group patients, systolic BP (23.63; P = 0.050), diastolic BP (24.01; P < 0.001), LDL cholesterol (20.21; P = 0.033), and PACIC subscores (P < 0.001 to 0.048) significantly improved compared with control group patients. No differences between groups were shown in the SF-36 subscales. CONCLUSIONSA chronic care approach according to the CCM and involving practice nurses in diabetes care improved the cardiovascular risk profile and is experienced by patients as a better structured care. Our study showed that care according to the CCM can be implemented even in small primary care practices, which still represent the usual structure in most European health care systems.

Primary care for diabetes mellitus patients from the perspective of the care model for chronic conditions

“…This reality converges with international experiences, in countries that adopted a new specific care model for chronic conditions, which affirm their efficacy and efficiency to assist this population in its singular and plural aspects, expressed in their health-disease processes 6 , 20 .…”

“…Starting from an important international discussion at the end of the 20 th century and the start of the 21 st century about health care models that take into account the needs of people with chronic conditions, new care models have been created, such as the Chronic Care Model 5 , developed in the United States, which has been widely used in different countries around the world, with reports of successful experiences 6 .…”

The Future of Clinical Trials in Cardiovascular Medicine

“…One such trial tested involvement of practice nurses and implementation of a chronic care model in patients with diabetes mellitus. 59 This approach is especially useful when the primary intervention involves a method of practice or a complex group of interventions that are testing different healthcare delivery strategies, and may be more efficient, simpler to execute, and less expensive than traditional individual patient randomization approaches.…”

Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review

“…Another study had similar findings that the sub-scales except for DSD demonstrated significant improvements in post-implementation ratings [31]. However, the program led by Frei et al found statistically significant differences in changes over time between intervention and control group patients in all CCM components, yet did not find statistically significant differences in changes between different components over time [45].…”

“…Among all the studies included in this review, six programs stated the absence of blinding or randomization [20,35,37,40,43,44]; four programs reported that the follow-up period was too short for the adequate detection of significant outcomes [24,38,45,46]; whilst three programs had a relatively small sample size [21,28,47]. Selection bias in patient recruitment includes differences in illness status [35], racial and cultural diversity [36,37,48], as well as in socioeconomic status [35].…”