Improving the Management of Chronic Disease at Community Health Centers

Landon, Bruce E.; Hicks, LeRoi S.; O’Malley, A. James; Lieu, Tracy A.; Keegan, Thomas; McNeil, Barbara J.; Guadagnoli, Edward

doi:10.1056/nejmsa062860

Cited by 241 publications

(193 citation statements)

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“…1 Achieving blood pressure control (BP) in patients with hypertension reduces the risk of stroke and ischemic heart disease. [2][3][4] Despite everincreasing public health resources dedicated to improving BP control, [5][6][7] only half of the 78 million Americans with hypertension have their BP treated and controlled to the recommended value of below 140/90 mmHg. 8 Under new BP targets recommended by the Panel Members Appointed to the Eighth Joint National Committee (JNC 8), 9 BP is controlled in less than 60 % of hypertensive patients overall, and in less than 50 % of patients younger than 60 years of age.…”

Section: Introductionmentioning

confidence: 99%

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Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

et al. 2015

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BACKGROUND: Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE: We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN: We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS: We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS:We simulated a base case and improvements of 10 and 50 %, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100 % for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME: BP control at 52 weeks of follow-up was examined. RESULTS: Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18 % achieved BP control after 52 weeks using base-case assumptions. With 10/50 %/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71 %), compared with enhanced visit frequency (19/21/35 %) and medication adherence (19/23/26 %). When all three processes were idealized, the model predicted a BP control rate of 95 % at 52 weeks.CONCLUSION: Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.

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Section: Introductionmentioning

confidence: 99%

“…12,13 However, quality improvement efforts in other clinical settings have failed to achieve similar success. 5 A better understanding of the expected relative effectiveness of different types of interventions could inform public health efforts and facilitate a more cost-effective use of resources.…”

Section: Introductionmentioning

confidence: 99%

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

et al. 2015

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“…36,[42][43][44] Recent chart audit studies showed inconsistent improvement in A1c, BP, and LDL, depending on the length of the period after the initiative. 16,[45][46][47] This study had a relatively short period after the program (1 year), yet significant improvements were found. Future research could employ a longer period to examine the impact over time and to determine the spread and sustainability of the results reported herein.…”

Section: Discussionmentioning

confidence: 91%

Results of a Mixed-Methods Evaluation of Partnerships for Health: A Quality Improvement Initiative for Diabetes Care

Harris

Paquette-Warren

Roberts

et al. 2013

The Journal of the American Board of Family Medicine

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Purpose: Quality improvement (QI) initiatives have been implemented to facilitate transition to a chronic disease management approach in primary health care. However, the effect of QI initiatives on diabetes clinical processes and outcomes remains unclear. This article reports the effect of Partnerships for Health, a QI program implemented in Southwestern Ontario, Canada, on diabetes clinical process and outcome measures and describes program participants' views of elements that influenced their ability to reach desired improvements.Methods: Part of an external, concurrent, comprehensive, mixed-methods evaluation of Partnerships for Health, a before/after audit of 30 charts of patient of program physicians (n ‫؍‬ 35) and semistructured interviews with program participants (physicians and allied health providers) were conducted.Results: The proportion of patients (n ‫؍‬ 998) with a documented test/examination for the following clinical processes significantly improved (P < .005): glycosylated hemoglobin (A1c), cholesterol, albumin-to-creatinine ratio, serum creatinine, glomerular filtration rate, electrocardiogram, foot/eye/neuropathy examination, body mass index, waist circumference, and depression screening. Data showed intensification of treatment and significant improvement in the number of patients at target for lowdensity lipoprotein (LDL) and blood pressure (BP) (P < .001). Mean LDL and BP values decreased significantly (P < .01), and an analysis of patients above glycemic targets (A1c >7% at baseline) showed a significant decrease in mean A1c values (P < .01). Interview participants (n ‫؍‬ 55) described using a team approach, improved collaborative and proactive care through better tracking of patient data, and increased patient involvement as elements that positively influenced clinical processes and outcomes.

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“…Overweightness and obesity continue to rise among both adults and children, increasing the prevalence of chronic diseases in both groups. Multiple programs have been initiated to combat these health disparities, with differing levels of success [9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

“…In 2007, Landon [9] reported on a study of care at community based health clinics examining patients with diabetes, asthma and hypertension. These health clinics instituted quality improvement methods to change patient care.…”

Section: Introductionmentioning

confidence: 99%

Weight Management and Hypertension Services in a Rural Public Health Clinic

Sands¹

2012

J Community Med Health Edu

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Objective: To improve chronic disease health outcomes through a culturally competent, preventive care intervention for the underserved, economically disadvantaged, underinsured, and other people of a rural Alabama county.Design: One-group pre-test/post-test design.Setting: Public health department in a rural county in the Southeastern part of the United States.Methods: A free, weekly clinic was held at the county health department. The clinic was staffed by Samford University pharmacy and exercise science faculty, a public health pharmacy practice resident, senior pharmacy students, and undergraduate exercise science majors. During weekly visits patients had baseline measures assessed and they were interviewed on medication therapy, dietary practice, and exercise regimen. Weekly follow-up to previous sessions provided opportunities for health coaching and monitoring of goal-setting. Results:The intervention clinic averaged 10 patients per week. Adult participants (n=357) had a mean age of 53.6±17.3. Comparison of year 1 (201.3±51.5) and year 2 (187.1±67.6) weight was statistically significant (p=0.004). Year 1 systolic blood pressure was 141.6±18.4 mmHg and diastolic blood pressure was 79.2±10.6. Where follow-up measures were available (n=81), the year 2 systolic blood pressure was 139.2±20.4 mmHg while the year 2 diastolic blood pressure was 77.1±11.8 mmHg. Year 1 BMI was 32.1±12.7 and year 2 BMI was 31.5±14.9 (n=23). Conclusion:Preventive services provided by pharmacists and health educators had a statistically significant effect on weight loss. While not statistically significant, clinical significance is noted on other key measures as blood pressure and BMI were trending in a positive direction. Further efforts towards weight loss will likely result in statistically significant changes to blood pressure and BMI.

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Improving the Management of Chronic Disease at Community Health Centers

Abstract: The Health Disparities Collaboratives significantly improved the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.

Cited by 241 publications

References 20 publications

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

Results of a Mixed-Methods Evaluation of Partnerships for Health: A Quality Improvement Initiative for Diabetes Care

Weight Management and Hypertension Services in a Rural Public Health Clinic

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